Systems and methods for installing an orthopedic implant

ABSTRACT

A system includes a cartridge having an elongate body extending from a first end to a second end and having a top side and a bottom side. The cartridge defines a first hole adjacent to the first end that extends through the cartridge from the bottom side to the top side. The top side of the cartridge defines a pair of parallel slots that extend perpendicular with respect to a longitudinal axis of the cartridge. Each slot of the pair of parallel slots is equidistant from a central axis defined by the first hole.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. Ser. No. 16/841,788, filedApr. 7, 2020, which is a continuation of U.S. patent application Ser.No. 15/933,924, filed Mar. 23, 2018 (now U.S. Pat. No. 10,646,238),which is a division of U.S. patent application Ser. No. 15/440,715,filed Feb. 23, 2017 (now U.S. Pat. No. 9,949,747), which is acontinuation of U.S. patent application Ser. No. 14/039,874, filed Sep.27, 2013 (now U.S. Pat. No. 9,675,365), which is a continuation of U.S.patent application Ser. No. 13/464,175, filed May 4, 2012 (now U.S. Pat.No. 8,808,297), which is a continuation-in-part of U.S. patentapplication Ser. No. 13/330,091 filed on Dec. 19, 2011 (now U.S. Pat.No. 8,808,303), which claims priority to U.S. Provisional PatentApplication No. 61/425,054 filed on Dec. 20, 2010 and to U.S.Provisional Patent Application No. 61/482,657 filed on May 5, 2011, andwhich is a continuation-in-part of U.S. patent application Ser. No.12/711,307 filed on Feb. 24, 2010 (now U.S. Pat. No. 9,113,914) claimingpriority to U.S. Provisional Patent Application No. 61/154,845 filed onFeb. 24, 2009, the entireties of which are herein incorporated byreference.

FIELD OF DISCLOSURE

The disclosed system and method generally relate to surgical guides.More specifically, the disclosed system and method relate to surgicalguides for orthopedic procedures involving an ankle.

BACKGROUND

Total joint replacement prostheses typically include a speciallydesigned jig or fixture to enable a surgeon to make accurate and precisebone resections in and around the joint being prepared to accept theprosthesis. The ultimate goal with any total joint prosthesis is toapproximate the function and structure of the natural, healthystructures that the prosthesis is replacing. Should the prosthesis notbe properly attached to the joint, i.e., an ankle or knee, themisalignment could result in discomfort to the patient, gait problems,or degradation of the prosthesis.

Many surgical procedures employ the use of intra-operative fluoroscopyto check the alignment of the intramedullary cavities that are preparedto receive the joint replacement prosthesis. However, the use ofintra-operative fluoroscopy in the operating room has several drawbacks.One such drawback is that the use of fluoroscopy to check the alignmentof intramedullary cavities formed during surgery increases the overalllength of the surgical procedure as time is taken to acquire andevaluate the fluoroscopic images. Long surgery times lead to increasedtourniquet time forth patient and therefore may increase recovery time.

Another drawback of fluoroscopy is exposing the patient and others inthe operating room to the ionized radiation. For example, the U.S. Foodand Drug Administration (“FDA”) has issued several articles and publichealth advisories concerning the use of the fluoroscopy during surgicalprocedures. Consequently, even though steps are taken to protect thepatient and other from the ionized radiation, it is virtually impossibleto eliminate all risk associated with the ionized radiation.

SUMMARY

In some embodiments, a system includes a cartridge having an elongatebody extending from a first end to a second end and having a top sideand a bottom side. The cartridge defines a first hole adjacent to thefirst end that extends through the cartridge from the bottom side to thetop side. The top side of the cartridge defines a pair of parallel slotsthat extend perpendicular with respect to a longitudinal axis of thecartridge. Each slot of the pair of parallel slots is equidistant from acentral axis defined by the first hole.

In some embodiments, a system includes a first component, a secondcomponent, and a third component. The first component has a bodydefining a first opening. The second component has a body defining ahollow interior and a first side that defines a second opening. Thesecond component is sized and configured to engage the first componentsuch that the second opening aligns with the first opening. The thirdcomponent has an elongate body extending from a first end to a secondend and having a top side and a bottom side. The third component definesa first hole adjacent to the first end that extends through thecartridge from the bottom side to the top side. The third component issized and configured to be received within the first opening defined bythe first component, the second opening defined by the second component,and the hollow interior of the second component when the first andsecond components are engaged.

In some embodiments, a method includes inserting a second component intoa resected joint space located between a first bone and a second bone;coupling a first component to the second component such that a firstopening defined by the first component aligns with a second openingdefined by the second component; and inserting a third component intothe first opening defined by the first component, the second openingdefined by the second component, and a hollow interior of the secondcomponent.

BRIEF DESCRIPTION OF THE DRAWINGS

These and other features and advantages of the present invention will bemore fully disclosed in, or rendered obvious by, the following detaileddescription of the preferred embodiment of the invention, which is to beconsidered together with the accompanying drawings wherein like numbersrefer to like parts and further wherein:

FIG. 1 illustrates the bones of a human foot and ankle;

FIGS. 2A and 2B are schematic representations of a scanned image of ahuman foot and ankle joint;

FIG. 3 is a perspective view of tibial and talar resection guideslocated upon portions of a tibia and a talus;

FIG. 4 is an exploded perspective view of a tibial cutting guide mountand tibial resection guide;

FIG. 5 is a perspective view of a tibial cutting guide disposed within atibial cutting guide mount located on an inferior portion of a tibia;

FIG. 6 is a front elevational view of a tibial cutting guide disposedwithin a tibial cutting guide mount located on an inferior portion of atibia;

FIG. 7 is a side elevational view of a tibial cutting guide disposedwithin a tibial cutting guide mount located on an inferior portion of atibia during resection of the tibia;

FIG. 8 is a schematic representation of a resected tibia followingapplication and use of the tibial cutting guide and tibial cutting guidemount;

FIG. 9 is a perspective view of a talar cutting guide disposed within atalar cutting guide mount;

FIG. 10 is an exploded perspective view of the talar cutting guide mountand the talar cutting guide illustrated in FIG. 9 ;

FIG. 11 is a perspective view of the talar cutting guide disposed withinthe talar cutting guide mount located on a superior portion of a talus;

FIG. 12 is a front elevational view of the talar cutting guide disposedwithin the talar cutting guide mount located on a superior portion of atalus;

FIG. 13 is a side perspective view of the talar cutting guide disposedwithin the talar cutting guide mount located on a superior portion of atalus during resection of the talus;

FIG. 14 is a schematic representation of a resected talus followingapplication and use of the talar cutting guide and talar cutting guidemount;

FIG. 15 is a schematic representation of a resected joint spacefollowing application and use of the talar and tibial cutting guidemounts and cutting guides;

FIG. 16 is a perspective view of one example of a custom tibial drillguide mount;

FIG. 17 is a front elevational view of the tibial drill guide mountillustrated in FIG. 16 ;

FIG. 18 is a rear elevation view of the tibial drill guide mountillustrated in FIG. 16 ;

FIG. 19 is a bottom elevational view of the tibial drill guide mountillustrated in FIG. 16 ;

FIG. 20 is a top elevational view of the tibial drill guide mountillustrated in FIG. 16 ;

FIG. 21 is a perspective view of one example of a tibial drill guide;

FIG. 22 is a side elevational view of the tibial drill guide illustratedin FIG. 21 ;

FIG. 23 is a top elevational view of the tibial drill guide illustratedin FIG. 21 ;

FIG. 24 is an exploded perspective view of the tibial drill guide mountand the tibial drill guide;

FIG. 25A is a side elevational view of the tibial drill guide disposedwithin the tibial drill guide mount being inserted into resected jointspace;

FIG. 25B is a perspective view of the assemblage of the tibial drillguide mount and tibial drill guide disposed within the resected jointspace;

FIG. 25C is a perspective view of the assembly of the tibial drill guidemount and tibial drill guide disposed and pinned within the resectedjoint space;

FIG. 26 is a perspective view of one example of an alignment tool;

FIG. 27 is an exploded perspective view of the alignment toolillustrated in FIG. 26 ;

FIGS. 28A and 28B illustrate the relative movement permitted betweeneach of the components of the alignment tool illustrated in FIG. 26 ;

FIG. 29 is a perspective view of one example of an adapter bar forcoupling the assemblage of the tibial drill guide mount and tibial drillguide to the alignment tool;

FIG. 30 is a perspective view of the adapter bar coupled to theassemblage of the tibial drill guide mount and tibial drill guide and tothe alignment tool;

FIG. 31 is a top isometric view of another example of an alignmenttool/foot holder assembly for use with a tibial drill guide mount andtibial drill guide;

FIG. 32 is a bottom isometric view of the alignment tool/foot holderassembly illustrated in FIG. 31 ;

FIG. 33 is an elevational front view of the alignment tool/foot holderassembly illustrated in FIG. 31 ;

FIG. 34 is an elevational side view of the alignment tool/foot holderassembly illustrated in FIG. 31 ;

FIG. 35 is a top isometric view of another example of an alignmenttool/foot holder assembly for use with the tibial drill guide mount andtibial drill guide;

FIG. 36 is a top elevational view of the alignment tool/foot holderassembly illustrated in FIG. 35 ;

FIG. 37 is an elevational front view of the alignment tool/foot holderassembly illustrated in FIG. 35 ;

FIG. 38 is an elevational side view of the alignment tool/foot holderassembly illustrated in FIG. 35 ;

FIG. 39 is a perspective view of another example of a tibial cuttingguide mount;

FIG. 40 is a front side elevational view of the tibial cutting guidemount illustrated in FIG. 39 ;

FIG. 41 is a side elevational view of the tibial cutting guide mountillustrated in FIG. 39 ;

FIG. 42 is a top side view of the tibial cutting guide mount illustratedin FIG. 39 ;

FIG. 43 is a bottom side view of the tibial cutting guide mountillustrated in FIG. 39 ;

FIG. 44 is a perspective view of a tibial drill guide cartridge for usewith the tibial drill guide mount illustrated in FIG. 39 ;

FIG. 45 is a front end view of the tibial drill guide cartridgeillustrated in FIG. 44 ;

FIG. 46 is a bottom side plan view of the tibial drill guide cartridgeillustrated in FIG. 44 ;

FIG. 47 is a side view of the tibial drill guide cartridge illustratedin FIG. 44 ;

FIG. 48 is an exploded perspective view of a mounting plate and dowelpins configured to for use with the tibial drill guide mount illustratedin FIG. 39 ;

FIG. 49 is a partially exploded perspective view of a mounting plate anddowel pins configured to for use with the tibial drill guide mountillustrated in FIG. 39 ;

FIG. 50 is a partially exploded perspective view of a mounting plate,dowel pins, and tibial drill guide mount configured to receive a tibialdrill guide cartridge in accordance with FIG. 44 ;

FIG. 51 is a perspective view of the tibial drill guide mount, tibialdrill guide cartridge, dowel pins, and mounting plate assembledtogether;

FIG. 52 is a side view of the assembly illustrated in FIG. 51 ;

FIG. 53 is a top side plan view of the assembly illustrated in FIG. 51 ;

FIG. 54 is a bottom side plan view of the assembly illustrated in FIG.51 ,

FIG. 55 is a perspective view of a foot holder assembly for use with theassembly illustrated in FIG. 51 ;

FIG. 56 is a perspective view of a pivoting arrangement used to securethe assembly illustrated in FIG. 51 to the foot holder assembly;

FIG. 57 is a top side plan view of the foot holder assembly illustratedin FIG. 55 ;

FIG. 58 is a side view of the foot holder assembly illustrated in FIG.55 ;

FIG. 59 is an opposite side view of the foot holder assembly illustratedin FIG. 55 ;

FIG. 60 is a rear end view of the foot holder assembly illustrated inFIG. 55 ;

FIG. 61 is a front end view of the foot holder assembly illustrated inFIG. 55 ;

FIG. 62 is a perspective view of a drill being extended through the footholder assembly and tibial drill guide;

FIG. 63 is an isometric view of one example of a reamer stabilizer inaccordance with some embodiments;

FIGS. 64 and 65 illustrate the reamer stabilizer illustrated in FIG. 63during various stages of operation;

FIG. 66 is an exploded isometric view of the reamer stabilizerillustrated in FIG. 63 ;

FIGS. 67 and 68 are cross-sectional detailed view of the couplingassembly of the reamer stabilizer illustrated in FIG. 63 during variousstages of operation;

FIG. 69 is a cross-sectional detail view of the coupling between aplunger rod, pivot rod, and reamer guide body in accordance with thereamer stabilizer illustrated in FIG. 63 ;

FIG. 70 is a cross-sectional detail view of the locking assembly of thereamer stabilizer illustrated in FIG. 63 ;

FIG. 71 is an isometric view of an embodiment of a foot holder assembly;

FIG. 72 is an isometric view of one example of a drill guide assemblythat is configured to be releasably coupled to the foot holder assemblyillustrated in FIG. 71 ;

FIG. 73 is a partial cross-sectional view of the drill guide assemblyillustrated in FIG. 72 ;

FIG. 74 is an isometric view of one example of a modified mountingmember in accordance with the foot holder assembly illustrated in FIG.71 ;

FIGS. 75 and 76 illustrate the coupling of the drill guide assemblyillustrated in FIG. 72 to the foot holder assembly illustrated in FIG.71 ;

FIG. 77 illustrates a trocar being received within the drill guideassembly;

FIGS. 78 and 79 illustrate a reamer stabilizer in accordance with FIG.63 being coupled to the foot holder assembly illustrated in FIG. 71 ;

FIG. 80 illustrates the drill guide assembly coupled to the foot of apatient during an operation;

FIG. 81 illustrates one example of an anterior reaming guide mountdisposed within a resected joint space in accordance with someembodiments;

FIG. 82 is an isometric view of one example of an insert for use withthe anterior reaming guide mount illustrated in FIG. 81 ;

FIG. 83 illustrates the insert illustrated in FIG. 82 disposed withinthe anterior reaming guide mount, which is received within a resectedjoint space;

FIG. 84 is a side view of a flexible reaming rod and reaming headdisposed within the insert illustrated in FIG. 82 ;

FIG. 85 is an isometric side view of the flexible reaming rod andreaming head disposed within the insert;

FIG. 86 is a front elevation view of the flexible reaming rod andreaming head disposed within the insert;

FIGS. 87-89 illustrate the reamer stabilizer, anterior reaming guidemount, and insert during various stages of an operation;

FIG. 90 illustrates another example of an anterior reaming guide mountand insert disposed within a resected joint space during an operation;

FIG. 91 are isometric side view of the insert illustrated in FIG. 90 ;

FIG. 92 is a side view of the insert disposed within the anteriorreaming guide mount in accordance with FIG. 90 ;

FIGS. 93 and 94 illustrate the reamer stabilizer in use with theanterior reaming guide mount and insert illustrated in FIG. 90 ;

FIGS. 95-100 illustrate another example of an anterior reaming guidemount.

DETAILED DESCRIPTION

This description of preferred embodiments is intended to be read inconnection with the accompanying drawings, which are to be consideredpart of the entire written description. The drawing figures are notnecessarily to scale and certain features may be shown exaggerated inscale or in somewhat schematic form in the interest of clarity andconciseness. In the description, relative terms such as “horizontal,”“vertical,” “up,” “down,” “top” and “bottom” as well as derivativesthereof (e.g., “horizontally,” “downwardly,” “upwardly,” etc.) should beconstrued to refer to the orientation as then described or as shown inthe drawing figure under discussion. These relative terms are forconvenience of description and normally are not intended to require aparticular orientation. Terms including “inwardly” versus “outwardly,”“longitudinal” versus “lateral” and the like are to be interpretedrelative to one another or relative to an axis of elongation, or an axisor center of rotation, as appropriate. Terms concerning attachments,coupling and the like, such as “connected” and “interconnected,” referto a relationship wherein structures are secured or attached to oneanother either directly or indirectly through intervening structures, aswell as both movable or rigid attachments or relationships, unlessexpressly described otherwise. When only a single machine isillustrated, the term “machine” shall also be taken to include anycollection of machines that individually or jointly execute a set (ormultiple sets) of instructions to perform any one or more of themethodologies discussed herein. The term “operatively connected” is suchan attachment, coupling or connection that allows the pertinentstructures to operate as intended by virtue of that relationship. In theclaims, means-plus-function clauses, if used, are intended to cover thestructures described, suggested, or rendered obvious by the writtendescription or drawings for performing the recited function, includingnot only structural equivalents but also equivalent structures.

The disclosed systems and methods advantageously utilize custommanufactured surgical instruments, guides, and/or fixtures that arebased upon a patient's anatomy to reduce the use of fluoroscopy during asurgical procedure. In some instances, the use of fluoroscopy during asurgical procedure may be eliminated altogether. The custom instruments,guides, and/or fixtures are created by imaging a patient's anatomy witha computer tomography scanner (“CT”), a magnetic resonance imagingmachine (“MRI”), or like medical imaging technology prior to surgery andutilizing these images to create patient-specific instruments, guides,and/or fixtures.

Although the following description of the custom patient-specificinstruments are described with respect to a foot 10 and ankle 12 (FIG. 1), one skilled in the art will understand that the systems and methodsmay be utilized in connection with other joints including, but notlimited to, knees, hips, shoulders, and the like. As shown in FIG. 1 , atypical human foot 10 includes an ankle joint 12 formed between a talus14, which is disposed on a calcaneus 20, and a tibia 16 and fibula 18.

A CT or MRI scanned image or series of images may be taken of apatient's ankle 12 (or other joint) and then converted from, e.g., aDICOM image format, to a solid computer model of the ankle including thecalcaneus, talus, tibia, navicular, and fibula to determine implantalignment, type, and sizing using specialized modeling methods that areoften embodied in computer software. Computer generated solid modelsthat are derived from the data of the CT or MRI scan image will ofteninclude precise and accurate information regarding the surface contourssurrounding the structures that have been imaged, e.g., the surfacetopography of the bones or contour of fascia that have been imaged. Itwill be understood that by surface topography it is meant the location,shape, size and distribution of surface features such as concavities andprominences or the like.

The methods disclosed in U.S. Pat. No. 5,768,134, issued to Swaelens etal., which is incorporated by reference herein in its entirety, havebeen found to yield adequate conversions of data of CT or MRI scanimages to solid computer models. In some embodiments, images are made ofa foot 10, i.e., the calcaneus 20, talus 14, tibia 16, and fibula 18 ofa patient using a CT or MRI machine, or other digital image capturingand processing unit as is understood by one skilled in the art. Theimage data is processed in a processing unit, after which a model 50 isgenerated using the processed digitized image data as illustrated inFIGS. 2A and 2B.

Interactive processing and preparation of the digitized image data isperformed, which includes the manipulation and introduction ofadditional extrinsic digital information, such as, predefined referencelocations 52 for component positioning and alignment so that adjustmentsto the surgical site 54, that will require resection during surgery, maybe planned and mapped onto computer model 50 (FIGS. 2A and 2B). Afterthe interactive processing of the digitized image data, it is possibleto go back to original CAD data to obtain a higher resolution digitalrepresentation of the patient specific surgical instruments, prostheses,guides, or fixtures so as to add that digital representation to thepatient's image data model.

FIG. 3 illustrates a pair of custom cutting guides for an anklereplacement surgery including a tibial resection guide mount 100 and atalar resection guide mount 102, which are formed and mounted to thepatient's lower tibia 16 a and upper talus 14 a. A custom tibial drillguide mount 200 (FIGS. 16-20 ) is also formed and configured to bereceived within ankle space created by using the custom tibial and talarresection guide mounts 100, 102. Although custom cutting guides aredescribed for preparing a patient's talus, tibia, and femur, one skilledin the art will understand that other cutting guides may be implementedand that custom guides may be created for other joints including, butnot limited to, the knee, hip, shoulder, or other joint.

Tibial resection guide mount 100 illustrated in FIG. 3 is formed from aresilient polymer material of the type that is suitable for use inconnection with stereo lithography, selective laser sintering, or likemanufacturing equipment. Resection guide mount 100 includes a unitarybody including a cruciform tibial yolk 104 projecting upwardly from abase 106 that further defines a guide receptacle recess 108 as best seenin FIG. 4 . Cruciform yolk 104 includes a pair of spaced apart arms 110,112 that project outwardly from a central post 114. Arms 110, 112 andcentral post 114 each have a conformal bone engaging surface 116 that iscomplementary to the contours of a corresponding portion of thepatient's lower tibia 16 a as illustrated in FIG. 7 . Through thepreviously discussed imaging operations, conformal bone engagingsurfaces 116 of arms 110, 112 and central post 114 are configured forcomplementary matching with anatomical surface features of a selectedregion of the patient's natural bone. For tibial resection guide mount100, the selected bone region comprises the lower surfaces of thepatient's tibia 16 a.

As best seen in FIGS. 3-5 , a pilot block 118 projects outwardly fromcentral post 114, adjacent to the intersection of arms 110, 112. Asupport block 120 (FIG. 4 ) is located on base 106 in spaced relation topilot block 118. Guide receptacle recess 108 is defined by a pair ofwings 122, 124 that extend outwardly from either side of central post114 in opposite directions on base 106, with support block 120 locatedbetween them. Each wing 122, 124 includes a respective pylon 126projecting outwardly from base 106 so as to provide lateral support fortibial resection guide 132 (FIGS. 4 and 5 ). An elongate slot 128 isdefined transversely in a central portion of base 106 below pilot block118, but above support block 120. Each wing 122, 124 also defines arespective slot 130 that is oriented at an angle relative to centralpost 114. In some embodiments, slots 130 are disposed at anon-perpendicular angle relative to central post 114, although oneskilled in the art will understand that slots 130 may be disposed atperpendicular angles with respect to the direction in which central post114 extends. Slots 128 and 130 are sized and shaped to allow a typicalsurgical saw 60 (FIG. 7 ) of the type often used for bone resection, topass through from a correspondingly positioned and sized slot inresection guide 132 without contact, or with only incidental contactwith resection guide mount 100.

Referring again to FIG. 4 , tibial resection guide 132 includes a pairof arms 134 that project downwardly and outwardly in diverging angularrelation from the ends of a bridge beam 136. The shape of tibialresection guide 132 is complementary to the shape of guide receptaclerecess 108 as defined by the inwardly facing surfaces of pilot block118, support block 120, and pylons 126. Bridge beam 136 defines anelongate slot 138 that aligns with slot 128 when tibial resection guideis coupled to and supported by resection guide mount 100. Arms 134 eachdefine a respective slot 140 that align with a respective slot 130.

The inwardly facing surfaces 142 of pilot block 118, support block 120,and pylons 126, that together define guide receptacle recess 108, have ashape that is complementary to the outer profile of tibial resectionguide 132. Guide receptacle recess 108 is sized so as to accept tibialresection guide 132 with a “press-fit”. By press-fit it should beunderstood that the inwardly facing surfaces 142 of pilot block 118,support block 120, and pylons 126 are sufficiently resilient to deflector compress elastically so as to store elastic energy when tibialresection guide 132 is pushed into guide receptacle recess 108. Ofcourse, it will also be understood that tibial resection guide 132 willhave an outer peripheral shape that is complementary to thecircumferential shape of guide receptacle recess 108, but slightlylarger in size, for press-fit embodiments. Also, tibial resection guide132 may be retained within guide receptacle recess 108 by onlyfrictional engagement with the inwardly facing surfaces of pilot block118, support block 120, and pylons 126. In some embodiments, tibialresection guide 132 can simply slide into guide receptacle recess 108without operative contact or only incidental engagement with theinwardly facing surfaces of pilot block 118, support block 120, andpylons 126.

Referring now to FIGS. 9 and 10 , a talar resection guide mount 102 isformed from a resilient polymer material of the type that is suitablefor use in connection with stereo lithography, selective lasersintering, or the like manufacturing equipment, e.g., a polyamide powderrapid prototype material is suitable for use in connection withselective laser sintering. Talar resection guide mount 102 also includesa conformal bone engaging surface 144 that is complementary to thecontours of a corresponding portion of the patient's upper talus 14 a(FIGS. 11 and 13 ). Through the previously discussed imaging operations,conformal bone engaging surface 144 of talar resection guide mount 102is configured for complementary matching with anatomical surfacefeatures of a selected region of the patient's natural bone. For talarresection guide mount 102, the selected bone region comprises the outer,upper surfaces of the patient's talus.

Talar resection guide mount 102 comprises a unitary block that defines acentral guide receptacle recess 146 and a pair of through-bores 148(FIG. 10 ). Guide receptacle recess 146 is defined by the inwardlyfacing surfaces 150 of a pair of wings 152, 154 that project outwardly,in opposite directions from a base 156. Each wing 152, 154 includes apylon 158 projecting upwardly to support guide housing 160 such that anelongate slot 162 is defined within base 156 and below guide housing 160(FIGS. 10 and 11 ). Slot 162 is sized and shaped to allow a typicalsurgical saw 60, of the type often used for bone resection, to passthrough from a correspondingly positioned and sized slot 164 in talarresection guide 166 without contact, or with only incidental contactwith talar resection guide locator 102 (FIGS. 11 and 13 ). An annularwall 168, having a shape that is complementary to the outer profile oftalar resection guide 166, projects outwardly in substantiallyperpendicular relation to a back wall and so as to further defines guidereceptacle recess 146.

Still referring to FIGS. 9 and 10 , talar resection guide 166 includes apair of confronting, parallel plates 170, 172 that define elongate slot164 between them, and are joined to one another at their ends by wings174. In this way, the shape of talar resection guide 166 iscomplementary to the shape of guide receptacle recess 146 as defined bythe inwardly facing surfaces 150 of wings 152, 154, base 156, and pylons158. Guide receptacle recess 146 is sized so as to accept talarresection guide 166 with a press-fit. Of course, it will also beunderstood that talar resection guide 166 will have an outer peripheralshape that is complementary to the circumferential shape of guidereceptacle recess 146, but slightly larger in size, for press-fitembodiments. Also, talar resection guide 166 may be retained withinguide receptacle recess 146 by only frictional engagement with theinwardly facing surfaces 150 of wings 152, 154, base 156, and pylons158. In some embodiments, talar resection guide 166 can simply slideinto guide receptacle recess 146 without operative contact or onlyincidental engagement with the inwardly facing surfaces 150 of wings152, 154, base 156, and pylons 158.

Tibial drill guide mount 200 illustrated in FIGS. 16-20 also may befabricated from a resilient polymer material of the type that issuitable for use in connection with stereo lithography, selective lasersintering, or the like manufacturing equipment, e.g., a polyamide powderrepaid prototype material is suitable for use in connection withselective laser sintering. As shown in FIGS. 16-20 , tibial drill guidemount 200 includes a somewhat rectangular body 204 that defines anaperture 206 that extends from a top surface 208 of body 204 to a bottomsurface 210 of body 204. Top surface 208 of body 204 may include a pairof chamfers 212 that are sized and configured to be mate against theresected surfaces of the lower tibia 16 a (FIG. 8 ). Put another way,the top or upper surface 208 of body 204, including chamfers 212, iscomplementary to the geometry and locations of slots 138 and 140 oftibial resection guide 132.

Front side 214 of body 204 defines one or more blind holes 216. Asillustrated in the embodiment shown in FIG. 17 , body 204 may definethree blind holes 216-1, 216-2, and 216-3. In some embodiments, blindholes 216-1 and 216-2 may be reamed holes that are sized and configuredto receive a dowel pin, and blind hole 216-3 may also be a reamed holefor receiving a dowel pin or blind hole 216-3 may be threaded forengaging a screw as described below.

Aperture 206 may have a circular cross sectional area and include ashoulder 218 having a reduced diameter compared to aperture 206 andincludes an anti-rotational feature 220 as best seen in FIG. 20 .Anti-rotational feature 220 of shoulder 218 may include one or moreflats or other geometric structure(s) to prevent tibial drill guide 202from rotating with respect to tibial drill guide mount 200 when tibialdrill guide 202 is disposed within aperture 206.

Extending from body 204 of tibial drill guide mount 200 are tibialengagement structure 222 and talar engagement structure 224. The outersurface 226 of tibial engagement structure 222 may have a rectangularshape that is substantially planar, and the internal and substantiallyconformal engagement surface 228 of tibial engagement structure 222 maybe somewhat convex for engaging the tibia 16 of the patient. Tibialengagement structure 222 may define one or more holes 230 for receivinga k-wire or pin as described below.

Talar engagement structure 224 may also include a substantially planarand rectangular outer surface 232. The lower portion 234 of talarengagement structure 224 may be a conformal surface having a geometrythat matches the geometry of the talar bone 14 (FIG. 14 ). Talarengagement structure 224 may also define one or more holes 236 sized andconfigured to receive a k-wire as described below.

Tibial drill guide 202 illustrated in FIGS. 21-23 is preferablyfabricated from a material having more structural integrity than tibialdrill guide mount 200 to enable drill guide 202 to guide a drill bitwithout being damaged. Examples of materials include, but are notlimited to, metals, ceramics, or the like. Drill guide 202 has acylindrically shaped first portion 238 that is sized and configured tobe received within the portion of aperture 206 that extends through theshoulder or reduced diameter area 218. A second portion 240 of drillguide 202 has a larger cross-sectional diameter than first portion 238and is sized and configured to be received within aperture 206 of tibialdrill guide mount 200. A flat 242, which is best seen in FIGS. 21 and 23, is formed along an exterior surface 244 of first portion 238 of drillguide 202. The internal surface 248 of second portion 240 of tibialdrill guide 202 has a conical shape that intersects and communicateswith aperture 246 such that a drill or reamer may be received throughdrill guide 202.

As with the digital image models 50 disclosed above, and considering ageneralized digital model of a tibial resection guide mount 100 added tothe patient's lower tibia image data, the anatomic surface features ofthe patient's lower tibia, e.g., the surface topography, may becomplementarily mapped onto each of conformal bone engaging surfaces 116of arms 110, 112, and central post 114, i.e., the surfaces that willengage the bones unique surface topography, of tibial resection guidemount 100. It will be understood that complementary mapping of thedigital images results in localized prominences on the surface of a bonebecoming localized concavities on conformal bone engaging surfaces 116of arms 110, 112, and central post 114 of tibial resection guide mount100, while localized concavities on the surface of a bone becomelocalized prominences on conformal bone engaging surfaces 116 of arms110, 112, and central post 114.

Each of conformal bone engaging surfaces 116 of arms 110, 112, andcentral post 114 of resection guide mount 100 is redefined with acomplementary, substantially mirror image of the anatomic surfacefeatures of a selected region of the patient's lower tibia 16 a. As aconsequence of this complementary bone surface mapping, tibial resectionguide mount 100 releasably “locks” on to the complementary topography ofthe corresponding portion of the patient's natural tibia without theneed for other external or internal guidance fixtures. In other words,the mating of bone surface asperities in their corresponding concavitiesformed in conformal bone engaging surfaces 116 of tibial resection guidemount 100 ensures that little or no relative movement, e.g., slippingsideways, occurs between tibial resection guide mount 100 and the tibialsurface.

A substantially identical mapping is carried out in connection with thedesign of a patient specific talar resection guide mount 102 and tibialdrill guide mount 200. Notably, the mapping for the design of tibialdrill guide mount 200 is performed by extrapolating where the resectionsto the tibia 16 and talus 14 will be made using tibial and talarresection guide mounts 100 and 102 and mapping the tibial drill guidemount 200 onto the extrapolated geometry of the tibia and talus.

A visual presentation of the virtual alignment results between thepatient's lower tibia 16 a and resection guide mount 100, the patient'supper talus 14 a and resection guide mount 102, and the proposedresected area that that is to be created by resecting the talus 14 andtibia utilizing the tibial resection guide mount 100 and the talarresection guide mount 102 are created and forwarded to the surgeon toobtain approval of the results prior to manufacturing. Additionally, thesurgeon may be provided with a visual representation of the virtualalignment results between the proposed resected joint space and tibialdrill guide mount 200 are created and forwarded to the surgeon to obtainapproval of the results prior to manufacturing. Upon receipt of thesurgeon's approval, resection guide mount 100, resection guide mount102, and tibial drill guide mount 200 are manufactured and returned tothe surgeon for use in the surgery.

During a total ankle replacement, for example, the surgeon makes ananterior incision to gain initial access to the ankle joint. The surgeonorients tibia resection guide mount 100 on lower tibia 16 a until theconformal bone engaging surfaces 116 of arms 110, 112 and central post114 of tibial resection guide mount 100 securely engage one another soas to releasably “interlock” with the topography of the exposed surfaceof lower tibia 16 a as best seen in FIGS. 5-7 . With tibial resectionguide mount 100 locked onto the patient's lower tibia 16 a, a surgeonpress-fits an appropriately configured distal resection guide 132 inguide receptacle recess 108 of tibial resection guide mount 100. Thisresults in the resection guide mount 100 being sandwiched between theresection guide 132 and the patient's bone tibia 16 a (FIGS. 5 and 6 ).With the resection guide mount 100 accurately positioned with respect tothe selected bone region and resection guide mount 100 constructappropriately secured to the patient's bone by virtue of the mating ofbone surface asperities in their corresponding concavities formed inconformal bone engaging surfaces 116, the surgeon uses a conventionalsurgical blade 60 and the resection slots 128 and 130 of resection guide132 to resect the patient's bone 16 (FIGS. 7 and 8 ).

In a similar fashion, when talar resection guide mount 102 is added tothe patient's talar image data, the anatomic surface features of thepatient's upper talus, e.g., the surface topography, may becomplementarily mapped onto conformal bone engaging surface 144. It willagain be understood that complementary mapping of the digital imagesresults in localized prominences on the surface of a bone becominglocalized concavities on conformal bone engaging surface 144, whilelocalized concavities on the surface of a bone become localizedprominences on conformal bone engaging surface 144. In this way,conformal bone engaging surface 144 is redefined with a complementary,substantially mirror image of the anatomic surface features of aselected region of the patient's lower tibia. As a consequence of thiscomplementary bone surface mapping, talar resection guide mount 102releasably “locks” on to the complementary topography of thecorresponding portion of the patient's natural talus without the needfor other external or internal guidance fixtures.

To continue the total ankle replacement the surgeon orients resectionguide mount 102 on upper talus 14 a until conformal bone engagingsurface 144 of resection guide mount 102 “locks” to the topography ofthe exposed surface of upper talus 14 a (FIG. 11 ). With resection guidemount 102 locked onto the patient's upper talus, a surgeon press-fits anappropriately configured distal resection guide 166 in guide receptaclerecess 146 of talar resection guide mount 102. This results in resectionguide mount 102 being sandwiched between resection guide 166 and thepatient's bone 14 (FIGS. 12 and 13 ). With the resection guide mount 102accurately positioned with respect to the selected bone region andresection guide 166 and guide mount 102 appropriately constructed andsecured to the patient's bone, by virtue of the mating of bone surfaceasperities in their corresponding concavities formed in conformal boneengaging surfaces 144, the surgeon uses a conventional surgical blade 60and the resection slot 164 of resection guide 166 to resect thepatient's bone 14 (FIGS. 13 and 14 ).

Once the tibia 16 and talus 14 have been resected, tibial drill guidemount 200 and tibial drill guide 202 are coupled together and installedinto resected joint space 22 (FIG. 15 ). Tibial drill guide mount 200and tibial drill guide 202 are coupled together by inserting firstportion 238 of tibial drill guide 202 into aperture 206 defined by body204 of tibial drill guide mount 200 (FIG. 24 ). Flat 242 formed on thefirst portion 238 of tibial drill guide 202 is aligned withanti-rotation feature 220 of shoulder 218 such that tibial drill guide202 slides into aperture 206 until a lower surface 250 of second portion240 of drill guide 202 contacts and abuts shoulder 218 of tibial drillguide mount 200.

Body 204 of tibial drill guide mount 200, in which tibial drill guide202 is disposed, is inserted into resected joint space 22 in an anteriorposterior direction with chamfers 212 sliding along resected areas oftibia 16 formed by utilizing slots 140 of tibial resection guide 132 asbest seen in FIGS. 25A and 25B. The assemblage of tibial drill guidemount 200 and tibial drill guide 202 are slid into resected joint space22 until talar engagement structure contacts talus 14. A surgeon maymove tibial guide mount 200 within resected joint space until conformalsurface 228 is appropriately secured to the patient's bone by virtue ofthe mating of bone surface asperities in their corresponding concavitiesformed in conformal bone engaging surface 228. Once properly located,k-wires 62 may be inserted into holes 230 and/or holes 236, respectivelydefined by tibial engagement structure 222 and talar engagementstructure 224, to secure the assemblage of the tibial drill guide mount200 and tibial drill guide 202 to the patient's tibia 16 and talus 14 asillustrated in FIG. 25C.

With tibial drill guide mount 200 and tibial drill guide 202 securedwithin resected joint space 22, the patient's leg is inserted into afoot holder and alignment tool 300. FIGS. 26-28B illustrate one exampleof an alignment tool 300, which serves the task of supporting the anklejoint during a prosthesis installation procedure. Alignment tool 300includes a foot holder assembly 302 and a leg rest 304. Foot holderassembly 302 includes a foot rest 306, to which the foot is secured by afoot clamp 310 and heel clamps 308 during an prosthesis installationprocedure. The calf of the leg is suitably secured to the leg rest 304once the ankle joint has been resected and tibial drill guide mount 200and tibial drill guide 200 have been installed. Together, foot holderassembly 302 and leg rest 304 hold the foot and ankle relative to theleg during an installation procedure.

As shown in FIG. 26 , foot holder assembly 302 is sized and configuredfor pivoting, under control of the physician, from a vertical or uprightcondition (shown in solid lines in FIG. 26 ) toward a more horizontal ortilted condition (shown in phantom lines in FIG. 26 ). In the uprightcondition, assembly 302 serves to hold the ankle joint in a desiredorientation with respect to the natural anterior-to-posterior andmedial-to-lateral axes.

As best seen in FIG. 27 , foot holder assembly 302 includes a back plate312 and a mid-plate 314, which is sandwiched between foot rest 306 andback plate 312. Mid-plate 314 is coupled to the foot rest 306 by slidingdovetail couplings 316 for up-and-down (i.e., vertical) movementrelative to foot rest 306. A pair of oppositely spaced alignment rods318 is carried by the mid-plate 314.

Alignment rods 318 are disposed in the same horizontal plane and extendfrom mid-plate 314 through vertically elongated slots 320 defined byfoot rest 306 such that rods 318 are disposed on opposite sides of thetibia in the medial-to-lateral plane when a foot is supported by footholder assembly 302. Vertical movement of mid-plate 314 moves alignmentrods 318 up-and-down in unison within slots 320 on opposite sides of thefoot rest 306 (FIG. 28A).

Back plate 312 is coupled to mid-plate 314 by sliding dovetail couplings322 for side-to-side (i.e., horizontal) movement relative to foot rest306 as illustrated in FIG. 28B. Back plate 312 also carries a bushing324, which extends through openings 326 defined by mid-plate 314 andfoot rest 306 and terminates at or near the plane of the foot rest 306against which the bottom of the foot contacts. The center of the bushing324 coincides with the intersection of the horizontal plane of the rods318.

An adapter bar 400 for coupling tibial drill guide mount 200 toalignment tool 300 is illustrated in FIG. 29 . Adapter bar 400 includesan elongate body 402 linearly extending from a first end 404 to a secondend 406. Each of the ends 404, 406 includes a respective extension 408,410 that extends from elongate body 402 at an angle. In someembodiments, extensions 408 and 410 orthogonally extend from elongatebody 402, although one skilled in the art will understand thatextensions 408 and 410 may diverge from elongate body 402 at otherangles. In some embodiments, elongate body 402 may not have a linearshape, but may have a curved or arced shape as will be understood by oneskilled in the art.

Each extension 408 and 410 defines a respective hole 412, 414 that issized and configured to slidably receive alignment rods 318 that extendfrom alignment tool 300. Elongate body 402 defines one or more holes416-1, 416-2, and 416-3 (collectively referred to as “holes 416”) forcoupling to adapter bar 400 to tibial drill guide mount 200. In someembodiments, the one or more holes 416 align with one or more holes 216defined by body 204 of tibial drill guide mount 200 such that a pin orother device for maintaining the alignment and engagement of adapter bar400 and tibial drill guide mount 200. For example, holes 216-1 and 216-2of tibial drill guide mount 200 align with holes 416-1 and 416-2 ofadapter bar 400, and hole 216-3 of drill guide mount 200 aligns withhole 416-3 of adapter bar 400. Dowel pins 70 (shown in FIG. 25C) may beinserted into holes 216-1 and 416-1 as well as into holes 216-2 and416-2 to align tibial drill guide mount 200 with adapter bar 400 in boththe horizontal and vertical directions (e.g., in the x- andy-directions), and a screw (not shown) may be inserted through hole416-3 into threaded hole 216-3 to secure tibial drill guide mount 200 toadapter bar at the proper height or depth (e.g., in the z-direction).

With tibial drill guide mount 200 and tibial drill guide 202 disposedwithin the resected ankle space 22, the foot and lower leg are placed infoot rest 306 and leg rest 304 (FIG. 30 ). The physician estimates theankle's axis of dorsi-plantar rotation and visually aligns the ankle tothe axis of rotation of the alignment tool 300. Foot rest 306 isadjusted to rotate the foot so that the big toe is essentially pointingin a vertical direction with respect to the leg that extends in ahorizontal direction. The forefoot and heel are secured to foot rest 306with clamps 308 and 310. Leg rest 304 is adjusted to the calf so thatthe tibia 16 is approximately parallel to the floor. The foot and calfare desirably aligned so that the anterior-posterior (“A-P”) line of thetalus's trochlea is essentially vertical.

Adapter bar 400 is coupled to alignment tool 300 by aligning holes 412and 414 that are respectively defined by extensions 408 and 410 withalignment rods 318 of alignment tool 300. Adapter bar 400 is then slidalong alignment rods 318 until holes 416 of adapter bar align with holes216 defined by body 204 of tibial drill guide 200 (FIG. 30 ). Asdescribed above, dowel pins 70 are inserted into holes 416-1 and 416-2of adapter bar 400 and holes 216-1 and 216-2 of tibial drill guide mount200. With dowels 70 disposed within holes 216-1, 216-2, 416-1, and416-2, tibial drill guide mount 200 is properly aligned with alignmenttool 300 in the medial lateral (e.g., x-direction) and superior-inferior(e.g., y-direction) directions. A screw is inserted through hole 416-3into threaded hole 216-3, which secures tibial drill guide mount 200 toadapter bar 400 and provides proper alignment in the anterior-posteriordirection (e.g., the z-direction).

With the patient's foot disposed within alignment tool 300, bushing 324on back plate 312 establishes alignment with the mechanical axis oftibia 16 and alignment of rods 318. Thus, after using adapter bar 400 toalign tibial drill guide mount 200 with alignment tool 300 as describedabove, in line drilling of the center of the ankle and tibia forintroduction of a bottom foot cannula is made possible without the useof fluoroscopy since aperture 246 of tibial drill guide 202 disposedwithin tibial drill guide mount 200 is aligned with an axis defined bybushing 324. Such arrangement enables an intramedullary channel to beformed that is substantially collinear with a mechanical axis defined bythe tibia.

Various minimally invasive surgical techniques may be used to introducea bottom foot cannula into the calcaneus 20, talus 14, and tibia 16. Inone representative embodiment, bushing 324 is temporarily separated fromthe back plate 312 (e.g., by unscrewing) to provide access to the bottomof the foot. The physician uses a scalpel to make an initial incision inthe bottom of the foot and replaces bushing 324. A cannulated trocarloaded with a k-wire (not shown) can be inserted through bushing 324,into the bottom of the foot, until the calcaneus 20 is contacted and thek-wire is firmly set within the calcaneus 20. The trocar can then beremoved, and the k-wire lightly tapped further into the calcaneus 20. Ina representative embodiment, the bushing 324 measures 6 mm in diameter,and the cannulated trocar can be 6 mm loaded with a 2.4 mm k-wire. Thephysician can now operate a cannulated first reamer (e.g., 6 mm) (notshown) over the k-wire up into the calcaneus 20 and talus 14. The firstreamer opens an access path for insertion of a bottom foot cannula.

After withdrawing the first reamer and bushing 324, the physician theninserts a bottom foot cannula 64 as shown in FIG. 30 . With the bottomfoot cannula 64 in place, a second reamer 66 (e.g., 5 mm) can beoperated through the cannula 64 to drill approximately another 100 mmthrough the talus 14 and up into the tibia 16 to establish anintramedullary guide path through the calcaneus 20 and talus 14 leadinginto the tibia 16 (FIG. 30 ). As second reamer 66 is advanced towardstibia 16, the tip 68 of reamer 66 is guided by the conical interiorsurface 248 of tibial drill guide 204, which is aligned with bushing 324of alignment tool 300.

Once an intramedullary channel through the calcaneus 20, talus 14, andtibia 16 has been established, adapter bar 400 is decoupled from drillguide mount 200 and alignment rods 318. Drill guide mount 200 is removedfrom resected joint space 22 to expose the resected joint space to thesurgeon.

With the resected ankle joint space 22 exposed to the surgeon, an ankleprosthesis is then installed. In one example, the ankle prosthesisincludes a stem that may extend from the bottom of the calcaneus up tothe top of the talus (i.e., a talo-calcaneal stem), although in someembodiment the stem is completely disposed within the talus (i.e., atalar stem). A convex dome is coupled to the stem and provides anarticulating joint surface. A tibial stem may be monolithic or include aplurality of segments that may be coupled together in situ. A tibialplatform couples to the tibial stem and either includes or is coupled toa convex joint surface for articulating with the articulating jointsurface coupled to the talar/talo-calcaneal stem. Examples of such ankleprosthesis and methods of installing such prosthesis are disclosed inU.S. Pat. No. 7,534,246 issued to Reiley et al., the entirety of whichis herein incorporated by reference.

The disclosed tibial drill guide mount 200 and drill guide 202 may beused with a variety of alternative alignment tools. For example, FIGS.31-34 illustrate another example of an alignment tool in the form of afoot holder assembly 500 to which tibial drill guide mount 200 may bedirectly coupled. As shown in FIGS. 31 and 32 , foot holder assembly 500includes a base plate 502 defining a plurality of slots 504 and 506 andan aperture 503.

Slots 504 are sized and configured to slidably receive a pair of heelclamps 508, and slots 506 are sized and configured to slidably receive apair of forefoot clamps or guides 510. Heel clamps 508 and forefootclamps 510 cooperate to maintain a foot of a patient in a desiredposition with respect to base plate 502 by utilizing a locking mechanismsuch as, for example, a set screw or other locking device, to fix theposition of heel clamps 508 and forefoot clamps 510 to base plate 502.The respective foot engaging surfaces 512 and 514 of heel clamps 508 andforefoot clamps 510 may have a shape that complements the medial andlateral shape of a human foot.

Extending from base plate 502 are a pair of alignment rods 516 that arearranged on base plate 502 such that one alignment rod is disposed on amedial side of a patient's foot and the other alignment rod is disposedon a lateral side of a patient's foot. A coupling bar 518 is sized andconfigured to slidably engage alignment rods 516 as best seen in FIGS.32 and 34 . Coupling bar 518 includes a pair of spaced apart legs 520that define channels 522 (FIG. 32 ) in which alignment rods 516 areslidably received. One or both of legs 520 include a clamp or otherlocking mechanism 524 for increasing the friction between coupling bar518 and alignment rods 516 in order to releasably lock coupling bar 518at a certain position along the length of alignment rods 516.

Medial-lateral cross bar 526 couples together legs 520 of coupling bar518. Extending from medial-lateral cross bar 526 is mount couplingmember 528. Mount coupling member 528 includes one or more holes 530-1,530-2, and 530-3 (collectively referred to as “holes 530”) that aresized and configured to align with holes 216 defined by tibial drillguide mount 200.

A peg 532 (FIG. 33 ) extends from medial-lateral cross bar 526 forcoupling shin engaging member 534 via slot 536 defined by shin engagingmember 534. Shin engaging member 534 includes a shelf 538 having aconcave surface 540 for abutting a shin of a patient. A nut or otherlocking mechanism (not shown) for engaging peg 532, which may bethreaded, may be used to fix the position of shelf 538 relative tomedial-lateral cross bar 526.

The use of foot holder assembly 500 in connection with the assemblage oftibial drill guide mount 200 and tibial drill guide 202 is similar tothe use of alignment tool 300 described above. For example, once theassembly of tibial drill guide mount 200 and tibial drill guide 202 aredisposed within resected joint space 22, the heel of the patient's footis placed between heel clamps 508 and the patient's forefoot is placedbetween forefoot clamps 510. The locking mechanisms of heel and forefootclamps 508 and 510 may be engaged to initially set positions of heel andforefoot clamps 508 and 510 relative to base plate 502.

Holes 530 of coupling member 528 are aligned with holes 216 defined bytibial drill guide mount 200 by sliding legs 520 of coupling bar 518along alignment rods 516. Dowel pins 70 and/or a threaded screw (notshown) may be used to couple holes 530 of coupling member 528 to holes216 of tibial drill guide mount 200. The surgeon may check to ensurethat the patient's foot is firmly against base plate 502 and then engageclamps 524 such that coupling bar 518 is fixed to alignment rods 516.

Shin engaging member 534 is adjusted until concave surface 540 contactsthe patient's shin. The adjustment of shin engaging member 534 is guidedby the engagement between slot 536 and peg 532. With shin engagingmember 534 in the desired position, the nut or other locking mechanism(not shown) locks shin engagement member 534 in place. The surgeon maymake final adjustments to the heel and forefoot clamps 508 and 510 andthen create the intramedullary channel as described above.

Another example of an alignment tool 600 for use with tibial drill guidemount 200 and tibial drill guide 202 is illustrated in FIGS. 35-38 . Asshown in FIG. 35 , alignment tool 600 includes a base plate 602comprising a plurality of bars 602 a, 602 b, and 602 c. Although threebars 602 a, 602 b, and 602 c are illustrated, one skilled in the artwill understand that fewer or more bars may be implemented. Bar 602 bdefines a hole 603 sized and configured to receive a surgical tool, suchas, for example, a cannulated drill. Additional elements including, butnot limited to, heel clamps and/or forefoot clamps (not shown) may becoupled to the bars 602 a, 602 b, and 602 c of base plate 602 for aidingin the positioning of a patient's foot with respect to hole 603.

Extending from base plate 602 is a pair of spaced apart alignment rods604. One of alignment rods 604 may be disposed on a medial side of apatient's leg, and the other alignment rod 604 disposed on a lateralside of the patient's leg. Alignment rods 604, like alignment rods 318of alignment tool 300, may be slidably receiving within holes 412, 414of adapter bar 400.

The use of alignment tool 600 in connection with the assemblage oftibial drill guide mount 200 and tibial drill guide 202 and the adapterbar 400 is similar to the use of alignment tool 300 described above. Forexample, once the assembly of tibial drill guide mount 200 and tibialdrill guide 202 are disposed within resected joint space 22, adapter bar400 is coupled to alignment tool 600 by aligning holes 412 and 414 thatare respectively defined by extensions 408 and 410 with alignment rods604 of alignment tool 600. Adapter bar 400 is slid along alignment rods604 until holes 416 of adapter bar align with holes 216 defined by body204 of tibial drill guide 200. As described above, dowel pins areinserted into holes 416-1 and 416-2 of adapter bar 400 and 216-1 and216-2 of tibial drill guide mount 200. With dowels disposed within holes216-1, 216-2, 416-1, and 416-2, tibial drill guide mount 200 is properlyaligned with alignment tool 600 in the medial lateral (e.g.,x-direction) and superior-inferior (e.g., y-direction) directions. Ascrew is inserted through hole 416-3 into threaded hole 216-3, whichsecures tibial drill guide mount 200 to adapter bar 400 and providesproper alignment in the anterior-posterior direction (e.g., thez-direction). The surgeon may make final adjustments to the heel andforefoot clamps 508 and 510 and then create the intramedullary channelas described above.

FIGS. 39-63 illustrate another embodiment of a system for performing asurgical procedure. Specifically, FIGS. 39-43 illustrate a tibial drillguide mount 700 sized and configured to receive the tibial drill guidecartridge 702 illustrated in FIGS. 44-47 . Tibial drill guide mount 700may also receive other drill guide cartridges for use during otherstages of the surgical procedures. Like tibial drill guide mount 200,tibial drill guide 700 may be fabricated from a resilient polymermaterial of the type that is suitable for use in connection with stereolithography, selective laser sintering, or the like manufacturingequipment, e.g., a polyamide powder repaid prototype material issuitable for use in connection with selective laser sintering.

As shown in FIG. 39-43 , tibial drill guide mount 700 has a somewhatrectangular body 704 having a front side 706, a rear side 708, top side710, bottom side 712, and a pair of opposed sides 714 and 716. Frontside 706 defines a recess 718 sized and configured to slidably receivetibial drill guide 702 therein. Recess 718 communicates with a recess720 (FIGS. 39 and 43 ) defined by bottom side 712 and a recess 722(FIGS. 39, 42, and 43 ) defined by top side 710 such that body 704 issubstantially hollow.

The respective inner surfaces 724, 726 of sides 714, 716 have differentgeometries that correspond with the cross-sectional geometry of tibialdrill guide cartridge 702 to ensure that tibial drill guide cartridge702 is properly inserted into recess 718. In the embodiment illustratedin FIGS. 39-43 , side 716 includes first and second ledges 728, 730 thatinwardly extend into recess 718, and side 714 has an inwardly taperedupper region 732 and an inwardly extending ledge 734. One skilled in theart will understand that sides 714, 716 may include other features forensuring proper insertion of tibial drill cartridge 702 into recess 718.In some embodiments, sides 714, 716 may have the identical geometry andtibial drill guide cartridge may be reversibly inserted into recess 718.

Front side 706 defines one or more dowel holes 736-1, 736-2(collectively referred to as “dowel holes 736”) sized and configured toreceive a dowel pin 70 therein. One or more through holes 738-1, 738-2,738-3 (collectively referred to as “through holes 738”) extend throughfront side 706, which also defines a blind hole 740. Through holes 738are sized and configured to receive k-wires for pinning tibial drillguide mount to a patient's bone as described below.

Top side 710 of tibial drill guide mount 700 includes a pair of chamfers742 that are sized and configured to be mate against and reference theresected surfaces of the lower tibia 16 a (FIG. 8 ). Tibial drill guidemount 700 also includes a tibial engagement structure 744 and a talarengagement structure 746. Tibial engagement structure 744 extends fromtop side 710 and includes a substantially conformal engagement surface748. Talar engagement structure 746 extends from bottom side 712 andalso includes a substantially conformal engagement surface 750.

Tibial drill guide cartridge 702 has a substantially rectangularelongate body 754 that may be formed from a more substantial materialthan tibial drill guide mount 700 such as, for example, metals,ceramics, or the like. As best seen in FIGS. 44 and 45 , the geometry ofsides 756, 758 is respectively complementary to the sides 714, 716 oftibial drill guide mount 700. For example, side 758 includes ledges 760and 762 that respectively correspond to ledges 728 and 730, and side 756includes a ledge 764 and an angled section 766, which respectivelycorrespond to ledge 734 and upper region 732 of tibial drill guide mount700.

Front side 768 of tibial drill guide cartridge 702 defines a blind hole770, which may be threaded for reasons described below. Tibial drillguide cartridge 702 defines a pair of holes 772 and 774 that extend frombottom surface 776 to top surface 778. Hole 772 may be a reamed holethat is sized and configured to receive a ball detent therein, and hole774 has an internal surface 780 that tapers from a larger diameter atbottom surface 776 to a smaller surface that is sized and configured toreceive a surgical tool, such as a drill and/or reamer. Top surface 778defines a pair of parallel slots 782-1, 782-2 (collectively referred toas “slots 782”) that extend from side 756 to side 758. As best seen inFIGS. 44 and 47 , slots 782 are disposed equidistant from a central axisdefined by hole 774 to provide a visual key for a physician that wantscheck the alignment of hole 774 with a mechanical axis of a patient'stibia using fluoroscopy.

As illustrated in FIGS. 48 , a mounting plate 800 has a substantiallyrectangular body 802 that is fabricated from a material including, butnot limited to, metals, ceramics, or the like. Body 802 defines anaperture 804 the extends from front side 806 to back side 808 and has asimilar geometry of recess 718 of tibial drill guide mount 700 such thattibial drill guide cartridge 702 may be received therein. Body 802 alsodefines a pair of through holes 810-1, 810-2 (collectively referred toas “holes 810”) that are arranged on body 802 such that they correspondto holes 738 of tibial drill guide mount 700 and are sized andconfigured to receive a k-wire or pin therein.

A mounting base 812 extends from front side 806 of mounting plate 800and defines a hole 814 that extends from a first side 816 to a secondside 818. Mounting base 812 defines a notch 820 and one or more dowelpin holes 822-1, 822-2 (collectively referred to as “holes 822”) thatare aligned with holes 736 of tibial drill guide mount 700. Notch 820bisects hole 814. Mounting base 812 may also define one or more recesses824 that correspond to one or more protrusions 784 that extends fromfront side 706 of tibial drill guide mount 700. Recesses 824 andprotrusions 784 cooperate to ensure that mounting base 812 and tibialdrill guide mount 700 are properly aligned. One skilled in the art willunderstand that other geometric features may be implemented to ensureproper alignment between mounting base 812 and tibial drill guide mount700.

As illustrated in FIGS. 49-54 , mounting plate 800 may be coupled totibial drill guide mount 700 using dowel pins 70, which are receivedthrough holes 822 and 734. Tibial drill guide cartridge 702 is receivedthrough aperture 804 and recess 718 as best seen in FIG. 51 . FIGS. 53and 54 illustrate that when tibial drill guide cartridge 702 is properlyinserted into the assemblage of tibial drill guide mount 700 andmounting plate 800, hole 772 aligns with hole 828 defined by mountingplate 800, which may include a ball detent (not shown) disposed therein.Consequently, the ball detent is received within hole 772 to retaintibial drill guide cartridge 702 disposed within aperture 804 and recess718 such that hole 774 is disposed within recesses 754 and 756. A screwor other threaded object (not shown) can be inserted into threaded hole770 and then pulled to remove tibial drill guide cartridge 702 fromaperture 804 and recess 718 as illustrated in FIGS. 53 and 54 .

Tibial drill guide mount 700, tibial drill guide 702, and mounting plate800 may be used in connection with alignment tool 300, adapter bar 400,foot holder assembly 500, and alignment tool 600 as described above.Additionally, tibial drill guide mount 700, tibial drill guide 702, andmounting plate 800 may also be used in conjunction with foot holderassembly 900 illustrated in FIGS. 55-60 as can tibial drill guide mount200 and tibial drill guide 202.

As shown in FIG. 55 , foot holder assembly 900 includes a base plate 902that extends from a first end 904 to a second end 906. First and secondends 904, 906 each define a pocket 908 and a hole 910. Pocket 908 issized and configured to receive a drill bushing 912 having a cylindricalbody defining hole 914 that aligns with through hole 910. Accordingly,both first end 904 and second end 906 may support an ankle or forefootof a patient. Each pocket 908 includes a spring loaded detent 916communicatively coupled to it that include a finger receiving surface918 and is configured to slide relative to base plate 902 and securedrill bushing 912 within pocket 908. In some embodiments, drill bushingmay be threaded and configured to be coupled to base plate 902 withcomplementary threads disposed on an inner surface of holes 910.

Base plate 902 also includes a medial/lateral extension 920 that extendsin a substantially perpendicular direction from an approximate mid-pointbetween first end 904 and second end 906. Base plate 902 may also definea viewing opening 922 such that a surgeon may be able to view the bottomof a patient's foot when the foot is secured to foot holder assembly900.

One or more rods 924 extend from base plate 902 in a substantiallyperpendicular direction with respect to an upper foot holding surface926 (FIG. 56 ). Rods 924 may be secured to base plate 902 using screwsor through other securing means as will be understood by one skilled inthe art. A cap 928 is secured to an upper end of rods 924 and be securedto rods 924 using screws or other fixation means.

A mounting member 930 has an elongate body 932 that defines a pair ofholes 934, 936 at one end 938 that slidably receive rods 924 such thatmounting member 930 may be slid along rods 924 in order to positiontibial drill guide mount 700 with respect to base plate 902. A springloaded button 940 is disposed at first end 938 of mounting member 930and is coupled to a locking mechanism (not shown) disposed withinmounting member 930 for locking mounting member 930 at a position alongrods 924.

One or more holes 942 are defined at the second end 944 of mountingmember 930 and correspond to holes 716 of drill guide mount 700 forcoupling drill guide mount 700 to foot holder assembly 900. Second end942 also defines a slot 946, as best seen in FIGS. 56 and 60 , that issized and configured to receive an internally threaded rod 948 of apivoting arrangement 950, which includes a lower portion 952 that isreceived within slot 820 of mounting plate 800 and is cross-pinnedthrough hole 814. The cross-pinning of pivoting arrangement 950 maypivot about an axis defined by hole 814 and is configured to receive ansupport tightening knob 954. Bottom surface 956 (FIG. 60 ) of knob 954has an outer dimension that is greater than slot 946 and is configuredto engage mounting member 930 in order to secure the assemblage ofmounting plate 800 and tibial drill guide mount 700, which may includetibial drill cartridge 702.

In operation, tibial drill guide mount 700 is inserted into resectedjoint space 22. Mounting plate 800 is connected to tibial drill guidemount 700 using dowel pins 70 as best seen in FIGS. 49 and 50 . Withpivoting arrangement 950 cross-pinned to mounting plate 800, theassemblage of mounting plate 800 and pivoting arrangement 948 is coupledto tibial drill guide mount with dowel pins 70, which may be press fitinto holes 822 of mounting plate 800 and holes 716 of tibial drill guidemount 700 as will be understood by one skilled in the art. Tibial drillguide mount 700 and mounting plate may be secured within resected jointspace 22 by inserting k-wires (not shown) into holes 736, 790 defined bytibial drill guide mount 700 and holes 830-1, 830-2 (corresponding toholes 736-1, 736-2) and 832-1, 832-2 defined by mounting plate 800.

With mounting plate 800 coupled to tibial drill guide mount 700 that isdisposed within resected joint space 22, pivoting arrangement 948 isrotated such that it extends in a direction approximately parallel to alongitudinal axis defined by a patient's leg and the cartridge-styletibial drill guide 702 is inserted into aperture 804 of mounting plate800 and recess 718 of tibial drill guide mount 700. Tibial drill guidecartridge 702 is inserted until leading end 786 of tibial drillcartridge 702 abuts rear wall 788 of tibial drill guide mount 700 atwhich point the ball detent disposed within hole 772 engages hole 828defined by mounting plate 800 and the front side 768 of tibial drillguide cartridge 702 is flush with front side 806 of mounting plate 800.

Holes 940 of mounting member 930 are aligned with, and received over,dowel pins 70 that extend from front side 806 of mounting plate tocouple mounting member 930 of foot holder assembly 900 to the assemblageof mounting plate 800, tibial drill guide mount 700, and tibial drillguide cartridge 702. With mounting member 903 coupled to dowel pins 70and mounting plate 800, pivoting arrangement 948 is rotated with respectto mounting plate 800 such that rod 946 of pivoting arrangement 948 isreceived within slot 944 of mounting member 930. Knob 952 is thenrotated about its axis (clockwise or counterclockwise) such that thebottom surface 954 of knob 952 contacts mounting member 930 to maintainengagement between mounting member 930 and the assemblage of tibialdrill guide mount 700 and mounting plate 800.

Drill bushing 912 is coupled to hole 910 that is aligned with the heelof a patient's foot. As described above, drill bushing 912 may be slidinto pocket 908 defined by bottom plate 902 until spring loaded detents916 releasably lock drill bushing 912 in place. In some embodiments,drill bushing 912 may be screwed into base plate 902 by way ofcorresponding threads disposed on an outer surface of drill bushing 912that engage threads defined by an inner surface of pocket 908 and/orhole 910. With drill bushing 912 in place and the patient's leg securedto foot holder assembly 900, various minimally invasive surgicaltechniques may be used to introduce a bottom foot cannula into thecalcaneus 20, talus 14, and tibia 16 as described above.

Once access to the patent's calcaneus has been achieved, a bottom footcannula 64 is inserted through the patient's calcaneus 20. A reamer 66is operated through the cannula 64 to drill approximately anotherthrough the talus 14 and up into the tibia 16 to establish anintramedullary guide path through the calcaneus 20 and talus 14 leadinginto the tibia 16. As reamer 66 exits talus 14, the conically shapedinternal surface 748 guides the tip 68 into hole 788. An axis defined byhole 788 is substantially axially aligned with a mechanical axis oftibia 16 such that as reamer 66 is extended through hole 788, it boresan intramedullary canal within tibia 16.

Reamer Stabilizer

FIGS. 63-70 illustrate one example of a reamer stabilizer 1000 that maybe used to stabilize the reamer as it is advanced into the tibia of apatient. Referring first to FIG. 63 , reamer stabilizer 1000 includes anelongate body 1002 extending from a distal end 1004 to a proximal end1006. As best seen in FIGS. 64 and 65 , body 1002 defines a longitudinalchannel 1008 extending along the length of body 1002. Body 1002 alsodefines a pair of cavities 1010, 1012 for receiving buttons and biasingmembers as described in greater detail below.

Distal end 1004 of body 1002 includes a pair of spaced apart prongs1014, 1016. In some embodiments, prong 1014 has a length that is longerthan a length of prong 1016. As shown in FIGS. 64 and 65 , longitudinalchannel 1008 extends along prong 1016. A notch 1018 is defined betweenprongs 1014 and 1016.

Proximal end 1004 includes a handle 1020 that extends at from body 1002at an angle relative to the longitudinal axis defined by body 1002 asbest seen in FIG. 63 . Opposite handle 1020 proximal end 1006 includes acutout region 1022 defined by a pair of perpendicular walls 1024, 1024as illustrated in FIG. 66 . Although walls 1024 are illustrated anddescribed as perpendicular to one another, one of ordinary skill in theart will understand that cutout region 1022 may be defined by wallshaving other configurations.

In some embodiments, body 1002 has a rectangular cross-sectionalgeometry defined by four sides 1026, 1028, 1030, 1032. Opposed sides1026, 1028 each include a respective step 1034, 1036 along theirrespective lengths. Steps 1034, 1036 are positioned at a same distancefrom notch 1018.

Opposed sides 1030, 1032 defines holes 1038, 1040, 1042 each configuredto receive a respective pin 1044, 1046, 1048 in a press-fit engagementas described below. Hole 1038 is positioned near proximal end 1006. Hole1040 is disposed adjacent to wall 1026 and step 1034. Hole 1042 isformed in prong 1016. In some embodiments, opposed sides 1030, 1032define an opening 1050, which reduces the overall weight of reamerstabilizer 1000 and provides a surgeon or user with additional surfacesto manipulate reamer stabilizer 1000.

As best seen in FIGS. 64 and 65 , a slidable guiding assembly 1052 isdisposed within longitudinal channel 1008. Guiding assembly 1052includes a reamer guide body 1054 that is pivotably coupled tostabilizer body 1002 by pin 1048, which is received within hole 1056.Reamer guide body 1054 includes a concave guiding surface 1058 disposedadjacent to hole 1056. Opposite concave guiding surface 1058 guide body1054 includes a step 1060, which is disposed adjacent to a hole 1062,which is defined in a forked end 1064 of guide body 1054. Formed end1064 is formed by a pair of spaced apart tabs 1066, 1068 that togetherdefine a recess 1070 therebetween.

A pin 1072 (FIGS. 66 and 67 ) is received in hole 1062 of reamer guidebody 1054 for pivotably coupling reamer guide body 1054 to pivot rod1074, which includes a corresponding hole 1076 at its distal end 1078.Pivot rod 1074 defines another hole 1080 at its proximal end 1084. Hole1080 is sized and configured to receive a pin 1082 for coupling pivotrod 1074 to plunger rod 1086.

As best seen in FIGS. 66-69 , plunger rod 1086 defines a hole 1088 atits distal end 1090, which has a flared geometry relative to theremainder of plunger rod 1086. In some embodiments, distal end 1090includes a pair of opposed flats 1092, 1094 and defines a slot 1096 asbest seen in FIG. 69 in which pivot rod 1074 is received. Distal end1090 also forms a shoulder 1091 configured to maintain plunger rod 1086within longitudinal channel 1008 as described in greater detail below.

Proximal end 1098 of plunger rod 1086 defines a hole 1100 that is sizeand configured to receive a pin 1118 for coupling plunger rod 1086 tohead 1102. Head 1102 defines a blind hole 1104 that inwardly extend fromdistal end 1106 and is sized and configured to receive proximal end 1098of plunger rod 1086 therein. In some embodiments, top side 1108 of head1102 includes an angled surface 1110 that terminates at side 1112. Head1102 also includes an arced surface 1114 for providing an ergonomiccontour to a user's finger (FIG. 70 ). A hole 1116 extends through head1102 in a direction that is perpendicular to the direction in whichblind hole 1104 extends and is configured to align with hole 1100 ofplunger rod 1086 for coupling plunger rod 1086 to head 1102 using pin1118. Although a cross-pin arrangement is described, one of ordinaryskill in the art will understand that other coupling means may be usedto couple head 1102 to plunger rod 1086 including, but not limited to, ataper fit, ultrasonic welding, a snap fit arrangement, or the use ofadhesive to list but only a few possibilities.

A biasing member 1120 is configured to be disposed over plunger rod 1086and abut the distal end 1106 of head 1102. In some embodiments, biasingmember 1120 is a compression spring that applies a biasing force to head1102 in a proximal direction as biasing member 1120 is disposed betweendistal end 1106 and a reduced diameter area 1009 of longitudinal channel1008.

Turning now to FIG. 70 , locking assembly 1122 is disposed at theproximal end 1006 of reamer guide body 1002 and is configured to lockguiding assembly 1052 in a position in which guiding assembly 1052engages a reamer body 65 as described in greater detail below. Lockingassembly 1122 includes a locking button 1124 slidably coupled to reamerstabilizer body 1002. Locking button 1124 includes a lower portion 1126that is configured to be received within cavity 1022 defined bystabilizer body 1002 and an upper portion 1128 extending abovestabilizer body 1002 for facilitating engagement by a surgeon or otheruser.

In some embodiments, lower portion 1126 has a substantially rectangulargeometry comprising a bottom surface 1130, an internal side surface1132, and an outer side surface 1134. Bottom surface 1130 is flat andconfigured to slide along a surface of cavity 1010. The interfacebetween bottom surface 1130 and outer side surface 1134 includes anangled surface 1138 that is complementary to angled surface 1110 of head1102. A slot 1140 is defined by sides 1142, 1144. Slot 1140 extendsparallel to bottom surface 1130 and is sized and configured to receivepin 1044, which is received through hole 1038 defined by stabilizer body1002.

In some embodiments, upper portion 1128 has a triangular shape althoughone of ordinary skill in the art will understand that upper portion 1128can take on other geometric shapes. Upper portion 1128 includes asubstantially flat bottom surface 1146 configured to slide along anupper or proximal-most surface of handle 1020. Upper sides 1148, 1150form the other two sides of upper portion 1128. Side 1150 is curved tofacilitate ergonomic engagement with a finger of a surgeon or user.

A biasing member 1152 is disposed within cavity 1010 and is configuredto urge locking button 1124 away from handle 1020 and towards guidingassembly 1052. In some embodiments, such as the embodiment illustratedin FIGS. 66-70 , biasing member 1152 is a compression spring that isdisposed in cavity 1010 in an abutting relationship with inner sidesurface 1132 of lower portion 1126 of locking button 1124. Biasingmember 1152 is positioned such in cavity 1010 such that biasing member1152 is substantially collinear with slot 1140 to prevent rotation andjamming of locking button 1124 as will be understood by one of ordinaryskill in the art.

Coupling assembly 1154 is coupled to side 1026 of stabilizer body 1002and is configured to couple reamer stabilizer 1000 to other surgicaldevices as described in greater detail below. Coupling assembly 1154includes a pivoting button 1156 and a biasing member 1158. As best seenin FIG. 66 , pivoting button 1156 has an arcuate body 1160 extendingfrom a lower end 1162 to an upper end 1164. A pair of ears 1166, 1168extend from an approximate middle of body 1160 that together definedepression 1170. Each ear 1166, 1168 defines a respective hole 1172,1174 for receiving pin 1046.

Lower end 1162 includes a detent 1176 extending from inner surface 1178adjacent to depression 1170. A recess 1180, which is illustrated inFIGS. 64 and 65 , is defined within depression 1170 at a location thatis disposed proximally of holes 1172, 1174 defined by ears 1166, 1168.Detent 1176 is disposed distally of step 1034. The relative locations ofdetent 1176 with respect to step 1034 and recess 1180 with respect toholes 1172, 1174 are provided for coupling reamer stabilizer 1000 toother surgical device as described in greater detail below. Concaveouter surface 1182 provides an ergonomic surface for the finger of asurgeon or user of reamer stabilizer 1000 when the reamer stabilizer1000 is to be decoupled from other surgical devices.

To assemble reamer stabilizer 1000, guiding assembly 1052 is assembledby placing pivot rod 1074 within slot 1096 at the distal end 1090 ofplunger rod 1086. Pivot rod 1074 is coupled to plunger rod 1088 byinserting pin 1082 through holes 1080 and 1100. Reamer guide body 1054is coupled to the distal end 1078 of pivot rod 1074 by inserting pin1072 into holes 1062 and 1076.

Proximal end 1098 of plunger rod 1086 is inserted into longitudinalchannel 1008 at the opening at defined by 1016 at the distal end 1004 ofstabilizer body 1002. When shoulder 1091 defined by distal end 1090contacts reduced diameter area 1009 of longitudinal channel 1008,proximal end 1098 of plunger rod 1086 outwardly extends fromlongitudinal channel 1008. Biasing member 1116 is inserted intolongitudinal channel 1008 over plunger rod 1086 as is head 1102. Hole1116 of head 1102 is aligned with hole 1100 of plunger rod 1086 and thetwo pieces are coupled together by inserting pin 1118 through holes 1116and 1100. Reamer guide body 1054 is coupled to stabilizer body 1002 byinserting pin 1048 through holes 1042 and 1056.

With guiding assembly 1052 coupled to stabilizer body 1002, lockingassembly 1122 is coupled to stabilizer body 1002. Locking assembly 1122is coupled to stabilizer body 1002 by inserting biasing member 1152 intocavity 1010 defined by body 1002. Lower portion 1126 of locking button1124 is inserted into cavity 1010 until slot 1140 defined by lowerportion 1126 aligns with hole 1038 defined by body 1002. With slot 1140aligned with hole 1038, pin 1044 is inserted into hole 1038 and slot1140 to cross-pin locking button 1124 to body 1002.

Coupling assembly 1154 is installed by inserting biasing member 1158into cavity 1012, and pivoting button 1156 is placed over biasing member1158 such that holes 1172, 1174 defined by ears 1166, 1168 aligns withhole 1040 defined by body 1002. With holes 1166, 1168 aligned with hole1040, pin 1046 is inserted into the holes 1166, 1168, and 1040 to securepivoting button 1156 to body 1002.

Foot Holder Assembly

Reamer stabilizer 1000 is configured to be used in connection with afoot holder assembly such as foot holder assembly 1200 illustrated inFIG. 71 . Foot holder assembly 1200 includes a base plate 1202 having agenerally rectangular shape extending from a first side 1204 to a secondside 1206 an from a third side 1208 to a fourth side 1210.

A pair of biased detents 1212, 1214 are disposed at opposite ends ofside 1210 and are configured to couple foot plate 1326 and drill guideassembly 1260 to one of sides 1204, 1206 of base plate 1202 as describedin greater detail below. Foot plate 1326 and drill guide assembly 1260can advantageously be coupled to either of sides 1204, 1206 such thatfoot holder assembly 1200 is reversible and can be used for an operationon a patient's left and/or right foot and ankle. Detents 1212, 1214 eachinclude a respective finger-engaging surface 1216, 1218 that aremanipulated by a surgeon or other user to disengage foot plate 1326and/or drill guide assembly 1260 from base plate 1202.

Sides 1204, 1206 of base plate 1202 each define a pair of holes 1222,1224 that are sized and configured to receive pegs 1332, 1334 of footplate 1326 and pegs 1276, 1278 of drill guide assembly 1260 as describedin greater detail below. Sides 1204, 1206, 1208, 1210 collectivelydefine a viewing opening 1224 such that a surgeon may be able to viewthe bottom of a patient's foot when the foot is secured to foot holderassembly 1200.

One or more rods 1226, 1228 extend from side 1208 of base plate 1202 ina perpendicular direction with respect to the direction in which sides1204 and 1206 extend from side 1208. In some embodiments, rods 1226,1228 are secured to base plate 1202 using screws although one ofordinary skill in the art will understand that other securing means forsecuring rods 1226, 1228 to base plate 1202 can be used. A cap 1230 iscoupled to the ends of rods 1226, 1228 opposite the ends to which baseplate 1202 is coupled. Cap 1230 can also be coupled to rods 1226, 1228using screws or other securement means.

A mounting member 1232 having an elongate body 1234 that defines a pairof holes 1236, 1238 at one end 1240 for slidably receiving rods 1226,1228. A locking screw 1242 comprising a knob 1244 provides a lockingmechanism for locking mounting member 1232 at a certain position alongrods 1226, 1228. One or more holes 1246, 1248 are defined at the secondend 1250 of mounting member 1232 and correspond to holes 736 of drillguide mount 700 and holes 822 of modified mounting plate 800A, which isdescribed in greater detail below. Second end 1250 also defines a slot1252 that is sized and configured to receive an internally threaded rod948 of pivoting arrangement 950.

Drill guide assembly 1260 is now described with reference to FIGS. 72-73. Referring first to FIG. 72 , drill guide assembly 1260 includes arectangular base 1262 extending from a coupling end 1264 to an oppositeend 1266. Sides 1268, 1270 extend between ends 1264, 1266 and eachdefine a respective recess 1272, 1274 adjacent to coupling end 1264.Pegs 1276, 1278 extend from coupling end 1264 and are sized andconfigured to be received within holes 1220, 1222 defined by sides 1204,1206 of foot holder assembly 1200. Although two pegs 1276, 1278 areillustrated, one of ordinary skill in the art will understand that feweror more pegs may be implemented.

Top side 1280 defines one or more holes 1282-1, 1282-2, 1282-3, 1282-4,1282-5, 1282-6, 1282-7, 1282-8 (“holes 1282”) for receiving k-wires. Anopening 1284 is defined by top side 1280 and extends through base 1262to patient-contact side 1286, which is disposed opposite top side 1280.Opening 1284 enables a surgeon or other professional to view the bottomof a patient's foot. A passageway 1288 also extends through base 1262and is sized and configured to receive a locking bushing assembly 1290.

As best seen in FIG. 73 , locking bushing assembly 1290 includes acentral member 1292 that is coupled within passageway 1288. Centralmember 1292 includes a threaded flared region 1294 that is disposedadjacent to end 1296. A plurality of flexible prongs 1298 are disposedat end 1296 and have a tapered configuration that narrows from flaredregion 1294 to end 1296. Central member 1292 defines a bore 1300extending from end 1296 to end 1302. Bore 1300 is sized and configuredto receive a drill bushing as described in greater detail below.

A knob 1304 defines an internal space 1306 and a hole 1308 that alignswith bore 1300 of central member 1292. Inner surface 1310 adjacent toopen end 1312 of knob 1304 includes threads for engaging the threads ofthreaded flared region 1294 of central member 1292. Opposite open end1312, knob 1304 includes a plurality of outwardly extending grippingsurfaces 1314 at end 1316. Internally, end 1316 includes a taper 1318.Side wall 1320 of knob 1304 defines one or more holes 1322 for receivinga respective pin 1324 for preventing knob 1304 from being separated fromcentral member 1292.

Referring again to FIG. 71 , foot plate 1326 has a rectangular baseportion 1328 and a coupling portion 1330. Coupling portion 1330 includesa pair of pegs 1332, 1334 that are sized and configured to be receivedwithin holes 1222, 1223 defined by sides 1204, 1206 of base plate 1202.Sides 1336, 1338 each define a respective slot 1340, 1342 that are sizedand configured to receive biased detents 1212, 1214 of base plate 1202of foot holder assembly 1200.

Operation

The use of reamer stabilizer 1000, foot holder assembly 1200, drillguide assembly 1260, and foot plate 1326 is now described. As describedabove, a surgeon uses tibial resection guide mount 100 and tibialresection guide 132 to resect the inferior end of a patient's tibia 16and uses talar resection guide mount 102 and talar resection guide 166to resect the superior surface of a patient's talus 14 to createresected joint space 22 as illustrated in FIG. 15 .

Tibial drill guide mount 700 is inserted into resected joint space 22,and mounting plate 800A is connected to tibial drill guide mount 700using dowel pints in the same way mounting plate 800 is connected totibial drill guide mount 700 as described above with reference to FIGS.49 and 50 . Cartridge-style tibial drill guide 702 is inserted intoaperture 804 of mounting plate 800A and recess 718 of tibial drill guidemount 700. Tibial drill guide cartridge 702 is inserted until leadingend 786 of tibial drill cartridge 702 abuts rear wall 788 of tibialdrill guide mount 700 at which point the ball detent disposed withinhole 772 engages hole 828 defined by mounting plate 800 and the frontside 768 of tibial drill guide cartridge 702 is flush with front side806 of mounting plate 800A, which is illustrated in FIG. 74 .

Mounting member 1232 of foot holder assembly 1200 is coupled to tibialdrill guide mount 700 and mounting plate 800A using dowel pins 70. Forexample, holes 1246, 1248 defined by second end 1250 are aligned withand receive dowel pins 70 that extend from mounting plate 800A. Pivotingarrangement 948 of mounting member 800A is pivoted from a horizontalposition in which lower portion 952 is not received within slot 1252defined by mounting member 1232 to a vertical position in which lowerportion 952 is received within slot 1252. Knob 952 is rotated about itsaxis (clockwise or counterclockwise) such that the bottom surface 954 ofknob 952 contacts mounting member 1232 to maintain engagement betweenmounting member 1232 and the assemblage of tibial drill guide mount 700and mounting plate 800A.

As illustrated in FIGS. 75 and 76 , drill guide assembly 1260 is coupledto the appropriate side 1204, 1206 of base plate 1202 such that drillguide assembly 1260 will be disposed directly adjacent to the heel of apatient's foot. The coupling of drill guide assembly 1260 to base plate1202 includes inserting pegs 1276, 1278 into holes 1220 defined by side1204 or into holes 1222 defined by side 1206. As pegs 1276, 1278 areinserted into holes 1220 or 1222, biased detent 1212 or 1214 outwardlyflexes in response to contacting base 1262 of drill guide assembly 1260and is then urged into a locking engagement within one of slots 1272 or1274 defined by sides 1268, 1270 by a biasing member when a detent 1212or 1214 is aligned with a slot 1272 or 1274.

Foot plate 1326 is coupled to the side 1204, 1206 of base plate 1202that is opposite the side 1204, 1206 to which drill guide assembly 1260is coupled such that foot plate 1326 is disposed adjacent to theforefoot of the patient. The coupling of foot plate 1326 to base plate1202 includes inserting pegs 1332, 1334 into holes 1220 defined by side1204 or into holes 1222 defined by side 1206 of base plate 1202. As pegs1332, 1334 are inserted into holes 1220 or 1222, biased detent 1212 or1214 outwardly flexes in response to contacting coupling portion 1330 offoot plate 1326. Detent 1212 or 1214 is urged into a slot 1340 or 1342defined by a side 1336 or 1338 of coupling portion 1330 when detent 1212or 1214 is aligned with slot 1340 or 1342.

The distance between base plate 1202 and mounting member 1232 can beadjusted by unscrewing locking screw 1242 such that mounting member 1232can be slid along rods 1226, 1228. When the desired positioning ofmounting member 1232 relative to base plate 1202 has been achieved,locking screw 1242 is rotated to lock mounting member 1232 at itsposition along rods 1226, 1228.

A trocar 74, which is illustrated in FIG. 77 , having ink applied to itstip is inserted into bore 1300 defined by central member 1292 of lockingbushing assembly 1290 and touched the skin of the patient's foot tocreate a mark. Drill guide assembly 1260 is removed from its engagementwith base plate 1202 by pressing the biased detent 1212, 1214 that isengaged with a slot 1268, 1270 defined by base 1262 such that detent1212, 1214 is urged out of its engagement with the slot 1268, 1270. Withdetent 1212, 1214 disengaged from slot 1268, 1270, base 1262 is pulledaway from base 1202 until pegs 1278, 1280 are removed from holes 1220 or1222.

With drill guide assembly 1260 removed, access to the calcaneus 20 ofthe patient is made by making a small incision at the marked locationusing a scalpel or other surgical cutting tool. Drill guide assembly1260 is then re-coupled to base plate 1202 as described above.

A drill bushing or cannula (not shown) is inserted into bore 1300 andthen locked in place by rotating knob 1304 of locking bushing assembly1294. Rotating knob 1304 causes the threads formed on inner surface 1310of knob 1304 to engage the threads of threaded flared region 1294. Asknob 1304 is rotated in one direction, e.g., a clockwise direction, therotation of knob 1304 relative to central member 1292 causes knob 1304to be advanced along central member 1292 towards base 1262, whichresults in taper 1318 contacting flexible prongs 1298. Flexible prongs1298 are urged inwardly towards one another as knob 1304 moves towardsbase 1262 thereby providing a frictional lock between locking bushingassembly 1290 and drill bushing or cannula.

With drill bushing or cannula locked to locking bushing assembly 1290, adrill is used to create a pilot hole through the calcaneus 20, talus 14,and into tibia 16. As the drill exits talus 14, the conically shapedinternal surface 748 of tibial drill cartridge 702 guides the tip of thedrill into tibia 14. Once the pilot hole has been drilled to a desireddepth into tibia 14, the drill is backed out and tibial drill cartridge702 is removed from tibial drill guide mount 700. Removal of cartridge702 includes inserting a threaded dowel or rod into threaded blind hole770 and pulling on threaded dowel or rod to remove cartridge 702 fromtibial guide mount 700.

A reamer head 66 is inserted into the space vacated by cartridge 702 andis coupled to a driving rod 65 of a reamer that is received within thevacated space having been inserted through the drill bushing or cannulalocked in locking bushing assembly 1290.

Once reamer head 66 is coupled to reamer rod 65, reamer stabilizer 1000is secured to mounting plate 800A as described with reference to FIGS.78 and 79 . Distal end 1004 of stabilizer body 1002 is inserted intoaperture 804 of mounting plate 800A and into body 704 via recess 718defined by front side 706 of tibial drill guide mount 700. Reamerstabilizer 1000 continues to be advanced until steps 1034, 1036 contacttop surface 806 in an abutting relationship. With steps 1034, 1036contacting top surface 806, detent 1176 disposed on the inner surface1178 of pivoting button 1156 is received within slot 826 of mountingplate 800A.

When detent 1176 is disposed within slot 826 and reamer stabilizer 1000is coupled to mounting plate 800A, reamer driving rod 65 is receivedwithin notch 1018 defined at the distal end 1004 of stabilizer body1002. Guiding assembly 1052 is actuated such that reamer guide body 1054in combination with notch 1018 encloses and surrounds the reamer drivingrod 65 as best seen by comparing FIGS. 64 and 65 . Guiding assembly 1052is actuated by applying a downward pressure (i.e., pressure in a distaldirection) to head 1102, which urges plunger rod 1086 and pivot rod 1074in a distal direction. The movement of plunger rod 1086 and pivot rod1074 in the distal direction forces reamer guide body 1054 to pivotabout hole 1056, which is pinned to stabilizer body 1002 by pin 1042.The distal end 1078 of pivot rod 1074 may outwardly flex with respect tohole 1080 at the proximal end 1084 as reamer guide body 1054 pivotsabout hole 1056. Although reamer guide body 1054 is illustrated asentirely extending across notch 1018, one of ordinary skill in the artwill understand that reamer guide body 1054 will extend only partiallyacross notch 1018 in some embodiments.

Still referring to FIGS. 64 and 65 , locking assembly 1122 is configuredto automatically lock guiding assembly 1052 in its engaged position withthe reamer driving rod 65. Locking button 1124 is urged by biasingmember 1152 towards in the direction towards head 1102 such that, whenangled surface 1110 of head 1102 is disposed below angled surface 1138of locking button 1124, locking button 1124 slides over the head 1102 tomaintain the engagement of the reamer 65 and concave guiding surface1058 of reamer guide body 1054. The reamer 65, 66 is advanced into thepilot intramedullary channel previously formed by the drill while beingsupported by reamer stabilizer 1000, which maintains the direction inwhich reamer 65, 66 is advanced into tibia 16 and prevents the reamer65, 66 from wandering.

Once the intramedullary channel has been reamed to a desired depth, thereamer 65, 66 is retracted through the intramedullary channel until thereamer head 66 is received within the resected joint space 22. Reamerstabilizer 1000 is then removed from its engagement with reamer rod 65and mounting plate 800A. To disengage reamer stabilizer 1000 from itsengagement with the reamer 65, locking button 1124 is pushed in adirection away from head 1102 until locking button 1124 is receivedwithin cavity 1010 defined by stabilizer body 1002.

Biasing member 1120 of guiding assembly 1052, which is disposed inabutting contact with distal end 1106 of head 1102, causes head 1102,plunger rod 1086, and pivot rod 1074 to move in a proximal directionwhen locking button 1124 does not contact head 1102 or otherwise impedehead 1102 from moving in the proximal direction. The proximal movementof head 1102, plunger rod 1086, and pivot rod 1074 causes reamer guidebody 1054 to pivot about pin 1048 due to the cross-pinned engagementbetween pivot rod 1074 and reamer guide body 1054.

With guiding assembly 1054 disengaged from the reamer, reamer stabilizer1000 is disengaged from mounting plate 800A by pressing pivoting button1156 such that button 1156 pivots about pin 1076 and detent 1176 isremoved from its engagement with slot 826. Reamer stabilizer 1000 isthen pulled from aperture 804. The reamer head 66 is then removed fromresected joint space 22.

Knob 952 is rotated in a direction opposite to the direction in whichknob 952 was rotated to tighten pivoting arrangement to mounting member800A such that the bottom surface 954 loosens its frictional engagementwith mounting member 1232. Pivoting arrangement 948 is pivoted back to ahorizontal position, and locking screw 1242 of mounting member 1232 isloosened by rotating knob 1244 in a direction that is opposite thedirection in which knob 1244 was rotated to tighten locking screw 1242.Mounting member 1232 slides along rods 1226, 1228 as base plate 1202 ismoved away from the patient's foot.

With the drill bushing or cannula still disposed within the calcaneus 20and talus 14, drill guide assembly 1260 is decoupled from its engagementwith base plate 1202 in the same manner as described above. Foot holderassembly 1200 is then removed such that drill guide assembly 1260,tibial drill guide mount 700, and mounting plate 800A are still engagedwith the patient's foot. K-wires 62 used to maintain the position oftibial drill guide mount 700 and mounting plate 800A are removed, andthen tibial drill guide mount 700 and mounting plate 800A are removed.

With drill bushing or cannula still disposed within the calcaneus 20 andtalus 14, k-wires 62 are inserted through one or more holes 1282 tosecure drill guide assembly 1260 to the foot of the patient asillustrated in FIG. 80 . Once drill guide assembly 1260 is secured, atool for driving components of a modular ankle prosthesis into theintramedullary canal formed by the reamer is inserted through drillguide or cannula held by drill guide assembly 1260. The remainder of theinstallation prosthesis is described in U.S. Pat. No. 7,534,246 issuedto Reiley et al.

Anterior Approaches

The disclosed systems and methods described above can also be adapted toenable an intramedullary cavity to be formed in the tibia of a patientvia an anterior approach once resected joint space 22 has been formedusing tibial resection guide mount 100 and tibial resection guide 132 toresect the inferior end of a patient's tibial and uses talar resectionguide mount 102 and talar resection guide 166 to resect the superiorsurface of a patient's talus 14 to create resected joint space 22 asillustrated in FIG. 15 . The anterior approach of forming anintramedullary channel in a patient's tibia avoids drilling through thecalcaneus and talus of the patient.

Referring now to FIGS. 81-89 , a custom anterior reaming guide mount1400 is illustrated as being disposed within resected joint space 22.Reaming guide mount 1400 is formed from a resilient polymer material ofthe type that is suitable for use in connection with stereo lithography,selective laser sintering, or like manufacturing equipment.

Reaming guide mount 1400 includes a body 1402 having an inferior surface1404 configured to mate against the flat formed on the superior surfaceof the resected talus. The superior surface 1406 includes a pair ofopposed angled surfaces 1408 that are configured to correspond to thecuts made using tibial resection guide 166.

A mating portion 1410 extends from superior surface 1406 and includes aconformal bone engaging surface 1412, which is complementary to asurface of the patient's tibia 16. Mating portion 1410 defines holes1414, 1416 that are sized and configured to receive k-wires 62 forsecuring reaming guide mount 1400 to talus 16. Superior surface 1406also defines an opening 1418 through which a reamer head 66 can bereceived.

Body 1402 also includes a rear wall 1420 and a pair of opposed sidewalls 1422, 1424 that define a cavity 1426 with superior wall 1428 andinferior wall 1430. In some embodiments, the respective interfacesbetween superior wall 1428 and side walls 1422, 1424 include chamfers1432, 1434 or other geometric features used for properly locating insert1440.

As best seen in FIGS. 82,84, and 85 , insert 1440 has an overall shapethat is complementary to the internal geometry of cavity 1426 defined byreaming guide mount 1400 and can be fabricated from a more durablematerial than reaming guide mount 1400 such as, for example, a metalmaterial. In particular, insert 1440 includes an inferior surface 1442,a superior surface 1444, side surfaces 1446, 1448, and a front surface1450. Superior surface 1444 defines an opening 1452 (FIG. 85 ) throughwhich a reamer head 66 can be received as described in greater detailbelow.

Front surface 1450 also defines an opening 1454 that is sized such thata reamer head 66 can be received within opening 1454. Openings 1452 and1454 communicate with each other such that the reamer head insertedwithin opening 1454 can be received within opening 1452 via internalcommunication between the openings 1452, 1454. In some embodiments,opening 1454 is smaller than the size of a reamer head 66, but providesa surgeon access a reamer head 66 disposed within opening 1454 such thatreamer head 66 can be coupled to a reamer driving rod 65.

An angled front face 1456 is disposed between front face 1450 andinferior surface 1442. Angled front face 1456 defines a passageway 1458that extends from angled front face 1456 to bottom surface 1460 ofinternal chamber 1562. Passageway 1562 is sized and configured toreceive a flexible reamer.

In operation, reaming guide mount 1400 is inserted into resected jointspace 22. Angled surfaces 1408, 1410 of superior surface 1406 andconformal bone engaging surface 1414 precisely locate reaming guidemount 1400 within the resected joint space 22.

A reamer head 66 is inserted into opening 1452 defined by superiorsurface 1452 of insert 1440. Insert 1440 is inserted into cavity 1428until opening 1452 defined by superior surface 1444 of insert 1440aligns with opening 1420 defined by superior surface 1420 of reamingguide mount 1400. A reamer rod 65 is inserted into passageway 1458defined by angled front face 1456 and coupled to reamer head 66 disposedwithin opening 1452. A surgeon may insert one or more tools in opening1454 to secure reamer head 66 to reamer rod 65. Reamer head 66 can thenbe advanced into the patient's tibia 16.

In some embodiments, reamer stabilizer 1000 is used to in connectionwith reaming guide mount 1400 and insert 1440. For example and asillustrated in FIGS. 87-89 , with a reamer head 66 and reamer body 65assembled together within the construct of reaming guide mount 1400 andinsert 1440, which are disposed within resected joint space 22, reamerstabilizer 1000 is coupled to stabilizer driving rod 65. To couplereamer stabilizer 1000 to stabilizer driving rod 65, distal end 1004 ofstabilizer body 1002 is inserted into opening 1454 defined by frontsurface 1450 of insert 1440 until driving rod 65 is received withinnotch 1018 defined at the distal end 1004 of stabilizer body 1002.

Guiding assembly 1052 is actuated such that reamer guide body 1054 andnotch 1018 encloses and surrounds the reamer driving rod 65 as best seenin FIG. 89 . Guiding assembly 1052 is actuated by applying a downwardpressure (i.e., pressure in a distal direction) to head 1102, whichurges plunger rod 1086 and pivot rod 1074 in a distal direction. Themovement of plunger rod 1086 and pivot rod 1074 in the distal directionforces reamer guide body 1054 to pivot about hole 1056, which is pinnedto stabilizer body 1002 by pin 1042. The distal end 1078 of pivot rod1074 may outwardly flex with respect to hole 1080 at the proximal end1084 as reamer guide body 1054 pivots about hole 1056.

Locking assembly 1122 is configured to automatically lock guidingassembly 1052 in its engaged position with the reamer driving rod 65. Asdescribed above, locking button 1124 is urged by biasing member 1152towards in the direction towards head 1102 such that, when angledsurface 1110 of head 1102 is disposed below angled surface 1138 oflocking button 1124, locking button 1124 slides over the head 1102 tomaintain the engagement of the reamer rod 65 and concave guiding surface1058 of reamer guide body 1054.

The reamer 65, 66 is advanced into tibia 16 to form a reamedintramedullary channel while being supported by reamer stabilizer 1000,which maintains the direction in which reamer 65, 66 is advanced intotibia 16 and prevents the reamer 65, 66 from wandering within tibia 16.

Once the intramedullary channel has been reamed to a desired depth, thereamer 65, 66 is retracted through the intramedullary channel until thereamer head 66 is received within opening 1420 defined by superiorsurface 1406 of reaming guide mount 1400 and/or within opening 1452defined by superior surface 1444 defined by insert 1440. Reamerstabilizer 1000 is then removed from its engagement with reamer rod 65.

To disengage reamer stabilizer 1000 from its engagement with the reamerrod 65, locking button 1124 is pushed in a direction away from head 1102until locking button 1124 is received within cavity 1010 defined bystabilizer body 1002. Biasing member 1120 of guiding assembly 1052,which is disposed in abutting contact with distal end 1106 of head 1102,causes head 1102, plunger rod 1086, and pivot rod 1074 to move in aproximal direction when locking button 1124 does not contact head 1102or otherwise impede head 1102 from moving in the proximal direction. Theproximal movement of head 1102, plunger rod 1086, and pivot rod 1074causes reamer guide body 1054 to pivot about pin 1048 due to thecross-pinned engagement between pivot rod 1074 and reamer guide body1054. With guiding assembly 1054 disengaged from the reamer, reamerstabilizer 1000 is pulled out of opening 1454 defined by front surface1450 of insert 1440.

As will be understood by one of ordinary skill in the art, the size andshape of reaming guide mount and insert may be varied. For example,FIGS. 90-94 illustrate another embodiment of reaming guide mount 1500and insert 1540. As shown in FIGS. 90 and 92 , body 1502 of reamingguide mount 1500 has an inferior surface 1504 configured to mate againstthe flat formed on the superior surface of the resected talus. Thesuperior surface 1506 includes a pair of opposed angled surfaces 1508that are configured to correspond to the cuts made using tibialresection guide 166.

Mating portion 1510 extends from superior surface 1506 and includes aconformal bone engaging surface 1512 (FIG. 92 ), which is complementaryto a surface of the patient's tibia 16. Holes 1514, 1516 are defined bymating portion 1512 and are sized and configured to receive k-wires 62for securing reaming guide mount 1500 to talus 16. Superior surface 1508also defines an opening 1518 through which a reamer head 66 can bereceived.

Body 1502 also includes a rear wall 1520 (FIG. 92 ) and a pair ofopposed side walls 1524, 1526 that define a cavity 1526 with superiorwall 1528 and inferior wall 1530 (FIGS. 90 and 92 ). The respectiveinterfaces between superior wall 1528 and side walls 1524, 1526 includechamfers 1432, 1434 or other geometric features used for properlylocating insert 1540. An inwardly projecting structure 1538 extends fromside wall 1524.

As best seen in FIG. 91 , insert 1540 has a triangular wedge shape suchthat it is able to be received between inwardly projecting structure1538 and inferior wall 1530 of reaming guide mount 1500. Insert 1540includes an inferior surface 1542, a superior surface 1544, sidesurfaces 1546, 1548 (FIG. 94 ), and a front surface 1550. Angled frontface 1556 is disposed between front face 1550 and inferior surface 1542and defines a passageway 1558 that extends from angled front face 1556to superior surface 1544. Passageway 1558 is sized and configured toreceive a flexible reamer rod 65.

As shown in FIGS. 93 and 94 , reamer stabilizer 1000 is received withincavity 1526 adjacent to insert 1540 such that reamer stabilizer 1000abuts both inwardly projecting structure 1536 and insert 1540. Reamerstabilizer 1000 stabilizes reamer 65, 66 as reamer 65, 66 is advancedinto the tibia 16 of a patient as described above.

Another embodiment of an anterior reaming guide mount is illustrated inFIGS. 95-100 . Reaming guide mount 1600 includes a body 1062 having aninferior surface 1604 (FIG. 96 ) configured to mate against the flatformed on the superior surface of the resected talus 14. The superiorsurface 1606 includes a pair of opposed angled surfaces 1608 (FIGS. 99and 100 ) that are configured to correspond to the cuts made usingtibial resection guide 166.

Mating portion 1610 extends from superior surface 1606 and includes aconformal bone engaging surface 1614, which is complementary to asurface of the patient's tibia 16. Holes 1614, 1616 are defined bymating portion 1612 and are sized and configured to receive k-wires 62for securing reaming guide mount 1600 to talus 16. Superior surface 1606also defines an opening 1618 through which a reamer head 66 can bereceived.

Body 1602 also includes a front surface 1622 and an angled front surface1624 that defines a passageway 1626 that communicates with opening 1620.Passageway 1626 is configured to receive a flexible reamer driving rod65 that is to be coupled to a reamer head 66 disposed within opening 66.

The disclosed systems and methods advantageously utilize custommanufactured surgical instruments, guides, and/or fixtures that arebased upon a patient's anatomy to reduce the use of fluoroscopy during asurgical procedure. In some instances, the use of fluoroscopy during asurgical procedure may be eliminated altogether. The custom instruments,guides, and/or fixtures are created by imaging a patient's anatomy witha computer tomography scanner (“CT”), a magnetic resonance imagingmachine (“MRI”), or like medical imaging technology prior to surgery andutilizing these images to create patient-specific instruments, guides,and/or fixtures.

Although the invention has been described in terms of exemplaryembodiments, it is not limited thereto. Rather, the appended claimsshould be construed broadly, to include other variants and embodimentsof the invention, which may be made by those skilled in the art withoutdeparting from the scope and range of equivalents of the invention.

What is claimed is:
 1. A surgical device, comprising: an elongate bodyhaving a proximal end and a distal end with a step formed along at leastone side of the body, the distal end of the elongate body defining anotch sized and configured to receive a reamer; a coupling assemblysupported by the elongate body including (i) a reamer guide bodydisposed at the distal end of the elongate body and configured to movebetween a first position and a second position, and (ii) first andsecond rods disposed within a channel defined by the elongate body, thefirst rod coupled to a head extending outwardly from the longitudinalchannel, and the second rod pivotably coupled to the first rod and to anend of the reamer guide body; and a locking assembly supported by theelongate body, the locking assembly configured to releasably engage thecoupling assembly to maintain the reamer guide body in the secondposition, wherein the reamer guide body extends at least partiallyacross the notch in the second position.
 2. The surgical device of claim1, wherein the coupling assembly includes a biasing member disposedwithin the channel, the biasing member configured to bias the head in aproximal direction.
 3. The surgical device of claim 1, wherein thelocking assembly includes a button slidably positioned within a cavitydefined at the proximal end of the elongate body, and a biasing memberconfigured to urge the button in a direction towards the couplingassembly.
 4. The surgical device of claim 3, wherein a lower portion ofthe button includes an angled surface that complements an angled surfaceof a head of the coupling assembly.
 5. The surgical device of claim 1,further comprising a coupling assembly coupled to the elongate body, thecoupling assembly configured to releasably secure the surgical device toanother instrument in combination with the step.
 6. The surgical deviceof claim 5, wherein the coupling assembly includes a button pivotablycoupled to the side of the elongate body, and a biasing member disposedwithin a cavity formed along the side of the elongate body, the biasingmember configured to exert a force on the button.
 7. The surgical deviceof claim 6, wherein the button includes a detent at a first end that isdisposed opposed an end on which the biasing member exerts the force. 8.The surgical device of claim 1, wherein the reamer guide body includesan arcuate surface configured to support a reamer, the reamer guide bodydisposed adjacent to a first hole configured to receive a first pin forpivotably coupling the reamer guide body to the distal end of theelongate body, and a second hole is defined adjacent to the first hole,the second hole configured to receive a second pin for pivotablycoupling the reamer guide body to a pivoting rod of the couplingassembly.
 9. The surgical device of claim 1, wherein the couplingassembly includes a plunger rod disposed within a channel defined by theelongate body, a first end of the plunger rod is coupled to the pivotingrod, and a second end of the plunger rod is coupled to a head includingan upper portion that is disposed outwardly of the channel; and a firstbiasing member disposed within the channel, the biasing member disposedbetween a lower portion of the head and a reduced diameter area of thechannel defined by the elongate body, the biasing member configured tourge the head in a proximal direction.
 10. The surgical device of claim9, wherein the locking assembly includes a button slidably positionedwithin a cavity defined at the proximal end of the elongate body, and asecond biasing member configured to urge the button in a directiontowards the head of the coupling assembly.
 11. The surgical device ofclaim 10, wherein a lower portion of the button includes an angledsurface that complements an angled surface of the head of the couplingassembly.
 12. A reamer stabilizer, comprising: an elongate bodyextending from a proximal end to a distal end, the distal end of theelongate body defining a notch for receiving a reamer; a couplingassembly supported by the elongate body, the coupling assembly includinga reamer guide body pivotably coupled to the distal end of the elongatebody configured to releasably secure the reamer stabilizer to anotherinstrument in combination with a step formed along a side of theelongate body, the reamer guide body configured to move between a firstposition and a second position and including an arcuate surface forsupporting the reamer wherein the reamer guide body defines first andsecond holes, the first hole is configured to receive a first pin forpivotably coupling the reamer guide body to the distal end of theelongate body, and the second hole is configured to receive a second pinfor pivotably coupling the reamer guide body to a pivoting rod of thecoupling assembly; and a locking assembly slidably supported by theelongate body, the locking assembly configured to move between a thirdposition and a fourth position in which the locking assembly releasablyengages the coupling assembly to maintain the reamer guide body in thesecond position, wherein the reamer guide body extends at leastpartially across the notch in the second position.
 13. The reamerstabilizer of claim 12, wherein the coupling assembly includes a plungerrod disposed within a longitudinal channel defined by the elongate body,a first end of the plunger rod is coupled to the pivoting rod, and asecond end of the plunger rod is coupled to a head including an upperportion that is disposed outwardly of the elongate channel; and a firstbiasing member disposed within the elongate channel, the biasing memberdisposed between a lower portion of the head and a reduced diameter areaof the longitudinal channel defined by the elongate body, the biasingmember configured to urge the head in a proximal direction.
 14. Thereamer stabilizer of claim 12, wherein the locking assembly includes abutton slidably positioned within a cavity defined at the proximal endof the elongate body, and a second biasing member configured to urge thebutton in a direction towards the coupling assembly.
 15. The reamerstabilizer of claim 12, wherein the coupling assembly includes a buttonpivotably coupled to the side of the elongate body, and a biasing memberdisposed within a cavity formed along the side of the elongate body, thebiasing member configured to exert a force on the button.
 16. The reamerstabilizer of claim 15, wherein the button includes a detent at a firstend that is disposed opposed an end on which the biasing member exertsthe force.